Yelp: When I want to find a good burger…not find a doctor! Friday, May 15 2015 

people-hate-us-on-yelpMy son just finished his first year of college. He is a business major, and I am interested in the viewpoints of his age group of 19 to 20-year-olds. I asked him his perspective on social media and rating sites like “Yelp”, especially in the medical industry. I had to laugh when he responded, “These sites are good for when I want to find a burger, but not trying to find a doctor.” I did have a proud mom moment!

Though I may be a bit bias, I have to say I agree with him. I have never been one to follow the crowd. I would prefer to experience all that life has to offer and make my own mind up based on my experiences. I have found that the vast majority of people who post on these sites are usually malcontents and self-absorbed. As an Administrator of a physician practice, when a patient is trying to “get their way” they typically threaten to go to “Yelp”. It is a threat and a method of intimidation. Before “Yelp”, people would threaten to file a lawsuit or contact their Senator/Congressperson…even the President!

A good portion of patient demands are unreasonable or not in the best interest of patient care. Sometimes, the patient becomes threatening or abusive toward the staff, which results in the patient being fired from the practice. Unfortunately, due to HIPAA, there is no way to defend ourselves against these accusations. Those of us who experience this firsthand know that IF people were to hear the whole story, they would understand our perspective! Would you trust a drug-seeker who is mad because we would not provide opiates since the patient is on marijuana, albeit “legally” with a medical marijuana card? Perhaps the review you are reading is from someone who is upset that they have a high-deductible health plan, and now they owe money to their doctor.

I have discovered that some reviews are in error. I had a review that mentioned a particular physician that was never a member of our practice. The review was regarding a service that we have never provided. It is nearly impossible to redact these erroneous reviews. Why would one want to trust a review that was a mistake?

Then, there is the fact that Yelp will contact the business to “help” them with their business reviews and create more positive responses…for a price. A great article that discusses this can be found at:

Yelp and the Business of Extortion 2.0

Bottomline, leave the reviews to film or restaurant critics…and maybe not even then! Don’t trust strangers with ulterior motives in choosing your physician. Do you want your healthcare in the hands of a trained physician or an unknown person who is trying to lash out because they didn’t get their way?

What Insurance Companies Don’t Want You to Know! Friday, Oct 26 2012 

Finally! A long awaited and much anticipated book about ERISA by two well-respected leaders in the health care industry! This book will provide the secrets in getting claims paid, how to fight denials, and halt recoupments using the features within the ERISA regulations.

This is a must buy! Quite frankly, this is important even if you are a layperson covered under your employer’s group health plan! These are the secrets that your insurance company doesn’t want you or your doctor’s office to know!

Book Description

Publication Date: October 15, 2012
New book helps medical practices use the secrets within the ERISA regulations to their benefit to increase practice profitability The Medical Practice Guide to ERISA: Employee Retirement Income Security Act The Federal law ERISA (Employee Retirement Income Security Act) helps the majority of medical practices make carriers pay on claims that are now being denied, delayed and recouped. Only a small percentage of practices understand how ERISA works — yet with this new book, ERISA could possibly become a practice’s best friend! ERISA is complex and most medical practices, “Don’t know what they don’t know when it comes to dealing with ERISA!” Practices are in the dark in understanding how to protect their employer’s rights in collecting the monies owed them. ERISA regulates the practice s health benefits, health benefit payments, EOBs, and most importantly, appeal rights Using this book will allow the reader to not only capture the funds on thousands of dollars that the carriers are now unfairly denying, but will empower the reader to stop the unfair recoupments, illegal timely filing and improper appeal periods that carriers mistakenly quote to physicians and hospital offices. The authors map out the smart but ingeniously simple tactics that practices can use to force insurance carriers to honor their responsibilities on the policies owned by patients — and to convince the carriers to adhere to what the policies actually require them to cover. Providing an overview of the ERISA law, the Self/Verno book provides tips, tools and techniques to leverage ERISA for practice advantage. They take a close look at real-world ERISA situations, violations and outcomes. Armed with this roadmap, physicians and executive staff can better put their resources to work– leveraging ERISA to improve practice profitability. Noteworthy Features Clear Roadmap Written in layman’s terms so practice leaders can immediately begin to implement a strategy of getting claims paid, how to fight denials and halt recoupments. Practical Guidance Includes real world examples and case studies of how medical practices can use the ERISA rules to work for them. Also included is practical information on how to use the ERISA website and answers to the most frequently asked questions about ERISA. Templates to Get You Started Sample letters (describing exact situations and how they can be handled) will get you started and help your practice take control of the process. Selected Table of Contents Healthcare Basics Definitions Laws Employee Benefits Security Administration: Frequently Asked Questions about ERISA Using ERISA Claims Issues Sample Letters – Timely Filing Denial Response, Refund Demand Layperson Response, Unpaid Claims Letter, Incorrectly Paid Claims Letter, Bundling Denial Letter, Down Coding Letter, Payment to Patient Letter Additional Resources – Helpful Websites, Layperson Documents Authorized Representation, Assignment of Benefit Form

You can purchase through Amazon by clicking on this link:

http://www.amazon.com/The-Medical-Practice-Guide-ERISA/dp/0988304007/ref=pd_rhf_cr_p_t_1

OAISYS Call Recording Case Study Tuesday, Oct 2 2012 

A few years ago, I did a video case study for OAISYS on their call recording solutions. I never thought, until now, to include it on my blog…here goes!

http://www.youtube.com/watch?v=R6Ikzy87h5A&feature=plcp

 

 

 

 

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.

FOBT (Fecal Occult Blood Testing) Coding Fact Sheet Sunday, Aug 12 2012 

Erica Schwalm graciously allowed me to post her coding fact sheet for Fecal Occult Blood Testing. Thank you, Erica!

“My office was having a lot of billing errors related to billing for FOBTs so I made this coding fact sheet to help everyone (physicians and coders) out!  Perhaps it will be of some use to some of you as well.  82270 can NOT be billed for FOBT done via DRE, but 82272 can…  I was seeing a lot of providers trying to bill 82270 with wellness visits when they shouldn’t have been and then, on the other hand, I found many “problem” FOBT’s (82272) that were never billed for when they should’ve been.”

Erica D. Schwalm, CPC, CPC-GENSG, CMRS

http://www.ericacodes.com

FOBT (Fecal Occult Blood Testing) Coding Fact Sheet 

There are two types of FOBT – Screening (82270) & Diagnostic (82272)

1.  The SCREENING test is covered yearly for those aged 50 and over.  This is a preventive test done in the absence of any signs or symptoms.

The patient is given “Stool Cards” to take home and collect three consecutive specimens.  When complete, the pt sends the cards in for testing.  Once testing is complete, then we can bill for CPT code 82270Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided 3 cards or single triple card for consecutive collection).

We cannot bill for the test when the pt is given the cards, only once they are returned and interpreted.

We cannot bill for screening FOBT when done during a rectal exam because only one sample is tested.  This does not meet the qualification for the code.  This method is considered to be included in the payment for the office visit.

The only acceptable diagnosis for this is V76.51 (Screening for colorectal cancer)

 

2.  The DIAGNOSTIC test is covered when medically necessary for signs & symptoms without regard to patient age or frequency limitations.

The patient may be given “Stool Cards” to take home and collect 1 – 3 specimens.  When complete, the pt sends the cards in for testing. Once testing is complete, then we can bill for CPT code 82272Blood, occult, by peroxidase activity (eg, guaiac), qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening.

In some situations, the physician may perform the test during a rectal exam (e.g. pt comes in c/o abdominal pain and tarry stools, physician would need to know immediately if there is active GI bleed).  Unlike code 82270, this one CAN be billed even when only one specimen is tested.

Do not use a v-code.  Use the sign or symptom(s) that prompted the test (e.g. rectal bleed, abdominal pain, etc.)

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.

BLOG REVIEW: “Are Doctors Infected With The Stockholm Syndrome?” Saturday, May 2 2009 

A companion blog for The Yale Journal for Humanities in Medicine (http://yjhm.yale.edu)

Tuesday, February 17, 2009

Are Doctors Infected With The Stockholm Syndrome?

Medicare is a great social institution. It saves millions of people from financial destitution.

But many doctors feel unfairly treated by Medicare’s payment schedules. For the past two years Medicare has threatened to cut physician reimbursement by 10% in 2008 and by 20% in 2009. After an outcry from physicians, the cuts were eliminated and physicians were given increases of .5% and 1% respectively. Many physicians were relieved to see that the cuts were reduced and some groups including the AMA actually thanked the Medicare Payment Advisory Committee (MedPAC) for being so understanding.

But rather than thank Medicare for the tiny increases which some consider an insult, it would have been better if medicine’s leadership had preserved physicians’ honor and dignity by rejecting them outright.

This pattern of being threatened then given a small reprieve followed by thanking the oppressors bears great similarity to the so-called Stockholm Syndrome which Webster’s New World College Dictionary defines as a psychological state in which hostages sympathize or even become friendly with their captors.

When threatened by severe price cuts that seriously jeopardize their livelihoods doctors may not be kidnapped or locked in closets but they are hostages none the less. And thanking those who oppress them for being so understanding makes them victims of the Stockholm Syndrome.

Clearly, to go from a 20% cut to a 1% increase represents quite a difference in any physician’s income. But still, groveling before Medicare and thanking it for a puny 1% increase is wrong. This weak showing is sure to encourage private insurers to use the same strategy. By threatening to drop doctors from their lists for failure to conform to their standards for quality and cost-efficiency, private insurers will have another tool to control doctors. This control will become acute once electronic medical records are in place and every treatment, test, and consultation ordered by physicians will become instantaneously available to health insurers to see who conforms to their protocols and who doesn’t.

Far better for the future of medicine if its leadership had rejected Medicare’s 1% increase and dedicated the savings to lowering patients’ premiums.

Ed Volpintesta MD

_______________________________________________________________________________

My comment:

This is very true!  I think that this was premeditated by Medicare.  They knew physicians would not accept a small increase of 0.5% or 1%, so how do you get the health care industry to accept it?  Threaten a huge decrease in reimbursement and then come back at the 11th hour with the intended puny increase and act like you are doing physicians a favor…Medicare is a “hero”!  It’s crazy, but it has worked for years now.

Physicians are too busy to fight it because they have to see more and more patients to make ends meet.  So, the insurance companies, including Medicare, keep reimbursements low and physicians have to work harder, see more patients in an hour, and focus on documenting the notes to achieve adequate payment.  Now, we are seeing P4P…Pay for Performance…to get any further increases in reimbursement.  Sounds great right?  Is it really an increase?  I don’t think so.  To improve performance, the physician must reduce the number of patients seen and document more performance measures, which means their reimbursements will go down because they are not seeing as many patients as they did.  So, the increase will bring them up a bit IF they can prove that their performance measures are having a positive effect.  Sounds to me like the physician is working differently to receive the same amount of pay.

We are also looking at reimbursement incentives to implement Electronic Medical Records; however, this typically has made the physician slower and decreases the amount of patients that they can see in a day.  How is that effective for the bottom line?  The cost of EMR is extremely expensive.  In my practice of seven physicians, we are looking at over $100,000 to purchase an EMR.  How do we pay for it if we are seeing fewer patients each day?

Unfortunately, the government and insurance companies are developing regulations and policies without input or direct knowledge of how things actually work in a private practice.  In addition, there is no consistency between health plans, so it takes more employees to appeal denials and keep up with all the specific reimbursement policies.

Physicians in private practice are getting the life sucked out of them.  Insurance companies have created patient antagonism toward their physicians.  Society is pointing fingers at the cost of health care and implying that is the fault of the provider of services.  If that is the case, why do physicians make $100,000 to $300,000 a year, while insurance company executives make near a million or considerably more per year?  Why do the insurance premiums continually increase for both the patient and the employer, while the provider of service sees either flat or decreasing reimbursements?  Yet, insurance companies post health profits each quarter.
Charlene  Burgett, M.S.