Annual Demographics Update Monday, Jan 9 2017 

In an effort to provide an explanation of the various reasons that we update demographics, we are offering this information to try to help reduce frustration for our patients and staff. Many people think completing the demographics form is only for billing purposes; however, we update patient information for both clinical and insurance reasons as well.

First and foremost, our clinical staff relies on the most current patient demographics to reach patients to communicate results of tests and to schedule patients for follow-up appointments. Initially, they make several attempts using all phone numbers provided. We have experienced phones disconnected and voicemail boxes full, which will then result in our attempt to reach a patient by mailing a note asking the patient to call our office. The last option is to try the patient’s emergency contact and explain that we have an important message. We do not divulge any confidential information unless we have a signed Designated Party Authorization.

In addition, we need to provide current information to specialists when we are referring patients, as well as for prior authorizations for prescriptions, procedures, and testing. These are the primary clinical reasons for having the patient update their information on a regular basis.

From an insurance perspective, it is our contractual obligation with insurance companies to maintain accurate records and current patient demographics to provide the best care. We are audited by all health plans several times a year for Quality Measures and frequently are required to show proof of current information on file.

Roughly 25-30 years ago, patients would pay for their medical services and the physician’s office would give them a bill to submit their own insurance for reimbursement. Now, with participation contracts, the healthcare provider extends credit while we wait for the insurance company to process and pay the claim.

To file a claim, and receive the insurance reimbursement, we have to have the patient sign an “Assignment of Benefits” authorizing their insurance company to send the reimbursement to the provider rather than the patient. This Assignment of Benefits is part of our demographic update form.

We, like all businesses, try to keep our expenses down and make every effort to collect for all services rendered. We need current addresses to mail statements for balances due. Phone numbers are required for the collection process as well. Even though we update this information, we still receive returned mail that is unable to be forwarded, which requires our staff to invest time determining the patient’s new address and/or telephone number. Each statement mailed can cost up to $2.00 per envelope. The Billing and Collection process can be even more costly if we are unable to locate the patient and they end up in outside collection because the collection company charges a substantial percentage to collect the balance due.

We dislike the extra workload as much as the patient dislikes completing the form. Please be assured that we have only included the minimum necessary for the patient to update to make it a bit easier. We appreciate our patients’ consideration and effort.

Rule-Out, Probable, and Possible: Importance in Documentation Guidelines Friday, Dec 19 2014 

Rule outRule out: Term used in medicine, meaning to eliminate or exclude something from consideration. For example, a normal chest x-ray may “rule out” pneumonia.

Many of us in health care have always heard the directive “never code a rule-out, possible, or probable”, which is true for coding the diagnosis! However, when coding for Evaluation & Management, it is extremely helpful to document any illnesses/injuries that the physician is ruling out because that will support the physician’s medical decision making and will guide the non-clinical/administrative personnel in the physician’s thought processes.

In the “Medical Decision Making-Diagnoses or Management Options” section of the Documentation Guidelines, CMS specifically states, “For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of differential diagnoses or as a “possible”, “probable”, or “rule out” (R/O) diagnosis.” (http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf ; page 44)

In addition, CMS states, in the same document (page 43):

C. DOCUMENTATION OF THE COMPLEXITY OF MEDICAL DECISION MAKING
The levels of E/M services recognize four types of medical decision making (straightforward, low complexity, moderate complexity and high complexity). Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:
the number of possible diagnoses and/or the number of management options that must be considered;”

I highly encourage all physicians and mid-level providers to include their thought processes in their documentation guidelines. Remember, many of the “bean-counters” that decide the appropriateness of your documentation are not clinical!

ICD-10-CM implementation date is October 1, 2014 Saturday, Sep 1 2012 

The final rule setting the ICD-10-CM implementation date as October 1, 2014 was released by the Centers for Medicare & Medicaid Services (CMS) on August 24, 2012.

Why am I being Charged for my “FREE” physical? Saturday, Sep 1 2012 

Due to the Patient Protection and Affordable Care Act (PPACA), or commonly called “Obamacare”, Health Plans are starting to cover Preventive Medicine services at 100% with no copays, coinsurance or deductible. Unfortunately, insurance companies are not informing patients that dealing with medical issues during these preventive medicine visits will result in an out-of-pocket charge that could result in a co-payment, or a substantial out-of-pocket expense if they have not met their deductible. Insurance companies require all services to be itemized and coded appropriately. One of the primary reasons is to prevent the health plans from paying for services that are not covered. Providers cannot code problem visits as preventive because this would be insurance fraud and could result in the insurance company denying the claim, dropping the physician from their network, and/or, if a government plan, the physician can face imprisonment and fines.

This has resulted in patients becoming angry with their doctor’s offices. Many practices are trying to figure out how to deal with this issue. At my practice, we notify patients before their preventive visit by posting signs on the exam room walls and the medical assistant provides a written notification for the patient to sign that they understand the billing policy. We are also trying to have the physician alert the patient, during the preventive medicine visit, when their concerns become a medical visit and may result in an out-of-pocket expense to the patient. Depending on the severity of the patient’s concern, the physician may be obligated to address the medical issue because, if he didn’t, it could result in a bad outcome for the patient. For example, if the patient states that they have been dizzy and having terrible headaches, this could mean that the patient may have a brain tumor or other significant medical issue. If the physician ignored this complaint, it would harm the patient or could harm others if the patient were driving a vehicle and had an episode. In addition, this would easily become a malpractice lawsuit against the physician.

Some physicians have chosen not to do both a preventive medicine visit and a problem visit on the same day. If the patient is scheduled for a wellness visit and a problem comes up, the physician would either make the decision to change the visit to a problem-oriented visit and reschedule the preventive if the problem is high risk; or have the patient return to deal with the problem issue at a later date if the problem is a low risk. This method keeps the appointments separate and easier for the patient to understand the difference. The downside is that it requires the patient to come back for a second visit, taking additional time off work, to deal with something that could have been handled during one visit.

Congress approves measure averting 27 percent physician cut through 2012 Friday, Feb 17 2012 

Special Edition: SGR Update

Congress approves measure averting 27 percent physician cut through 2012

A House-Senate Conference Committee tasked with identifying a compromise to avoid the pending 27.4 percent Medicare physician payment cut reached a 10-month deal that would maintain current physician payment rates through the end of the year. The measure was approved this afternoon by both the House and Senate. The measure now goes to President Obama for his signature. The President is expected to sign the bill.

I’d rather buy a month’s worth of Starbucks than…pay my doctor bill Wednesday, Jul 6 2011 

One of the biggest frustrations we have in the health care industry is due to patients not understanding their own health insurance benefits. Oftentimes, patients think that just because they carry insurance, that means that everything is covered and they don’t have to pay anything. Patients receive health care service and a month later they discover that their insurance doesn’t cover that particular service; however, instead of accepting the responsibility of paying, many patients fight, demand, and threaten the physician’s office staff to make the balance go away.

This phenomenon has gotten worse in the past twenty years or so. I subscribe to the theory that much of this mentality is due to the inception of HMO’s. In the beginning, HMO’s had either zero patient financial responsibility, or an exceptionally low out-of-pocket cost. People have been conditioned in thinking that health care is an entitlement. After about a decade, due to insurance companies (and employer groups) not being able to withstand the expense of higher utilization of “free” health care, they began to make the consumer more responsible by charging higher co-pays and not covering certain services. Unfortunately, most Americans expect the same Cadillac coverage without any additional expense (beyond their insurance premium and co-pay).

A major challenge in physician practices is to help their patient’s understand their insurance company’s reimbursement policies, all the while maintaining good will. Physicians are finding themselves having to develop various financial informed consent forms to assure that the patient understands that they may be responsible for some of the cost. Medicare has required this, in the form of Advanced Beneficiary Notices (ABN), for years.  Even so, we often hear patients state, “I signed it but didn’t read it.”  Or, “I was afraid if I didn’t sign it that I wouldn’t get the service.” Perhaps the days of accountability are long gone.

One of the biggest threats we hear from patients is that they will leave our practice if we don’t write off their balance. Not much that you can do about that. Health care is a business and we cannot pay the bills with altruism. In addition, it is fraud to bill the insurance company for services and write off the patient’s responsibility. Aside from financial hardship cases, routine adjustments of patient responsibility can get a physician excluded and/or fined by the government when it is a government program such as Medicare or Medicaid. Worst case scenario for commercial insurance is the insurance company dropping the physician from their network.

With lower reimbursements, practices really need to devote more energy in collecting all revenues due. The average overhead for a primary care physician practice is reaching 60%. There are no government subsidies for physicians, other than rural health care, community health care centers and native american health centers. More and more physicians are closing their offices, retiring early, selling their practices to hospitals, transitioning to concierge medicine, or going to cash only practices. This is devastating to primary care because of the physician shortage; however, many specialists are also getting hit hard as well.

Burn Coding/Rule of Nines Monday, Apr 18 2011 

There are several CPT codes related to burn coding that I want to share with you to enhance your coding and reimbursement. These codes refer to local treatment of burned surface area only. When using these burns codes, remember to document percentage of body surface involved and depth of burn. Remember your “Rule of Nines” in calculating Total Body Surface Area!

  • 16000 Initial Treatment, first degree burn, when no more than local treatment is required.
  • 16020 Dressings AND/OR Debridement of partial thickness burns, Initial OR Subsequent; small (less than 5% total body surface area)
  • 16025 Dressings AND/OR Debridement of partial thickness burns, Initial OR Subsequent; medium (e.g. whole face or whole extremity, or 5% to 10% of total body surface area)
  • 16030 Dressings AND/OR Debridement of partial thickness burns, Initial OR Subsequent; large (e.g. more than one extremity, or greater than 10% of total body surface area)

 

These codes can be used in addition to an office visit; however, the office visit must be medically necessary and a modifier -25 must be appended to the office visit. An example of a medically necessary office visit would be to prescribe medications (such as antibiotics and/or pain medication, for example).

Rule of Nines Burn Chart for Adults

Rule of Nines Burn Chart for Infant

Gardasil (HPV Vaccine) approved for boys/young men Sunday, Aug 22 2010 

In the past several years, the FDA has approved new immunizations in an effort to prevent various illnesses, including sexually transmitted diseases that could result in cancer.  Once such vaccine, Gardasil, is “currently is approved for use in girls and women ages 9 through 26 for the prevention of cervical, vulvar and vaginal cancer caused by HPV types 16 and 18; precancerous lesions caused by types 6, 11, 16, and 18; and genital warts caused by types 6 and 11.”  In October 2009, the Food and Drug Administration announced that it approved the use of Gardasil vaccine for boys/men between the ages of 9 and 26 years of age, as well.

According to About.com, in providing Gardasil vaccines to young men, “the result would likely be:

  • less spreading of HPV
  • hopefully, fewer cases of cervical cancer in women
  • perhaps, a decrease in other types of cancer”

HPV can cause genital warts in men that may lead to several types of cancer, including oral, penile and anal cancers.

As with most new immunizations, it can take up to a year for this to process through to the insurance companies before they create policies to cover the vaccines.  At this point, Gardasil is covered by most health plans for girls and young women; however, the same is not true for boys and young men.  The Gardasil vaccine is quite expensive and requires a serious of three vaccines over a six month period that could cost in the range of $650-800 for the entire series.  It is recommended that you verify with your health plan, beforehand, whether or not they cover this vaccine, especially for the male gender.  If they do not cover this vaccine, it will result in the cost being transferred to patient responsibility.

FDA announcement:  http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm187003.htm

About.com:  http://cancer.about.com/od/hpvvaccine/a/hpv_vaccine_boys.htm

New Trick by the Health Insurance Industry Tuesday, Nov 3 2009 

Imagine that you are an independent contractor for a company that pays you a specific rate for a specified amount of work; however, if you do more than the specified amount of work you would receive an additional amount.  Now, if you were to do that additional amount of work separately you would receive 100 dollars.  But, if you do that additional amount of on the same day as your normal work load, you would receive your normal pay for your normal work load and 50 dollars for the additional amount of work.  Would that be acceptable to you?

To illustrate further, I do my work and earn $100.   Tomorrow, I fill in for someone else and do their work and earn $100.  Okay, that seems fair. Tomorrow, I not only do I do my job, but I also completely do someone else’s work.  As an independent contractor, should I receive $100 for my normal work and that’s it?  Should I receive $200 for a double workload?  How about if I only get $150…$100 for my work and $50 for completing someone else’s job?  I think many of us would say that I should receive $200!

Unfortunately, many physicians are experiencing the $150 example from health plans when it comes to providing medical care on the same day as a preventive medicine visit.  According to universal coding principles, it is expected that a physician will code an evaluation and management (Office Visit) for diagnostic (medical) issues when done on the same day as a preventive medicine (complete physical).  One of the primary reasons is so insurance companies do not have to reimburse for services outside their reimbursement policies; for example, if the patient does not have preventive medicine benefits but comes in for a physical, the physical can not be coded as a covered medical benefit just to get  paid.

In physician coding, we are trained to code all services accurately to represent what actually was performed and documented so as to not open the practice up to the risk of fraud and abuse allegations.  In theory, one would think that if there is a universal coding policy, then the service should be reimbursed in a consistent manner; however, this is not the case.  What we are seeing is that the majority of health plans will pay the problem visit at 50% and the physical at 100% (there’s your $150!).  A few others will not reimburse the problem visit at all on the same day as the physical (you only get $100…double the work at the pay of one job!).  Consequently, many physicians are telling patients that they cannot have both services performed on the same day, thus the physician is able to get full reimbursement for each service (aha! that’s where I put my $200!).

It is inconvenient to the patient to make two appointments; but with the increasing expenses that physician’s practices are having to absorb, it is just not possible to throw away all or half of a reimbursement.  In addition, it is inconvenient to other patients who are not able to get in to be seen because of the physician’s full schedules…or doing in two visits that which he can do in one.  Understandably so!  The physician should be reimbursed for all of his services fairly.  This will allow the physician to be able see additional patients who require medical attention and not play insurance games!

Woman charged extra for asking doctor too many questions Saturday, Aug 8 2009 

Woman charged extra for asking doctor too many questions | 3 ON YOUR SIDE |
Arizona | azfamily.com

by Gary Harper/3 On Your Side

August 5, 2009

A Valley woman says she has a billing problem with her doctor’s office.

The billing problem has to do with a “well woman exam,” basically it is an annual physical for women.

The woman you are about to meet says it was supposed to be covered 100% by her insurance carrier, so why does she keep getting billed by the doctor’s office?

Shannon Karal, like a lot of women, knows the importance of having an annual physical. She says, “I do all my preventative visits for dentist, doctor, any of the normal things I try to go as much as they say you should go.”

So Shannon scheduled a well woman exam at a physician’s office called Doctors Goodman and Partridge, an exam she says that is 100% covered by her insurance carrier. Shannon explains, “I just had some questions and concerns about normal things that a young woman like me would have.”

Shannon says the exam was completely paid for by her insurance, however, she keeps getting a bill for $92 from the doctor’s office so, she called to find out why and, according to Shannon, she was told she asked too many questions during her exam.

She admits, “It makes me feel like next time I go to the doctor I shouldn’t share any of my questions or concerns or take any more time out of their day because I might be charged extra for that.”

Shannon maintains the questions she asked during her exam were all normal “female-related” questions and she cannot believe she would be charged. “I would completely understand this extra charge if there was another test done or something they do for my questions. But nothing! It was all verbal.”

The office of Doctors Goodman and Partridge would not talk to 3 On Your Side about Shannon’s case citing privacy issues but after our inquiry, they sent Shannon a letter saying, “The problems evaluated and managed at that visit were above and beyond the scope of a normal well woman exam” but, Shannon says that is nonsense and feels she is being billed for asking too many female-related questions, and taking up too much of the doctor’s time. Shannon tells 3TV, “I feel like there’s a stop watch every time I go to the doctor and they’re gonna be timing me and making sure I don’t go over that time and if I do then ‘Oh, there might be an additional charge for this.'”

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