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!

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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

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.

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

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.'”

Helped Patient Battle Health Plan and Won! Sunday, Jul 5 2009 

Just about a week ago, I received a call from a patient who was extremely upset that she was being billed $1,400.00 by the imaging facility for a CT scan after we told her that she did not need a prior authorization from her insurance company.  Typically, this is one of those things that it’s our word against the insurance company and, historically, the insurance company seems to always win.  I guess the axiom “he who holds the money has the power” applies in this kind of situation.  The insurance company insisted that they did not have a record of our phone call to them and that they would never have told us that this patient did not need a prior authorization for the CT scan.  The patient was irate and understandably so…especially with the economy the way it is.  As a goodwill gesture and to keep peace with the patient, I would have accepted the responsibility and paid for the scan and our office would be out the money.

But…we voice record all our incoming and outgoing telephone calls using a system called Talkument.  I have all of the staff and physicians trained on what information is helpful to me when I need to investigate a telephone conversation.  In this case, I pulled the patient’s chart and the medical assistant wrote a note stating that she called the health plan on 5/23/09 at 3:13 pm and found out that no prior authorization was needed and that she talked with Ann.  I knew my medical assistant’s extension and searched based on the information that I had, and viola, I found the four minute telephone conversation between my medical assistant and the health plan representative, Ann, who said that the patient did not need a prior authorization for the CT scan!

I had a three way conference call between the patient, myself and the health plan where I played the recording for them.  The patient was ecstatic!  I had to play this information a couple of levels up the ladder and was still told that someone would have to get back to me (quite frankly, I don’t think they were ready to address the fact that the doctor’s office actually had recorded them!  Uh oh!  They were caught!)

About a week later, the health plan representative called me and stated that they would cover the cost of this CT scan “this one time”.  She still did not want to take responsibility for her company giving inaccurate information.  She made it sound like we doctored up the recording…even though we have caller ID that had the health plan’s toll-free number and the first two minutes of the recording was the automated system that announces the health plan name.  I was even told by the rep that the person with whom my medical assistant had talked with, Ann, was not an employee of this health plan.  I love the lack of accountability!

Defensive medicine is taking on a new definition.  Besides the Internet, the next best resource I have in my office is the voice documentation system for phone call recording!  The system has aided me with staffing issues, patient issues and now insurance issues.  It has definitely paid for itself in protecting my physicians and our office from lying and deceit.

Rating physicians on websites Sunday, May 24 2009 

I’ve been troubled by the fact that patients can go to websites that allow them to rate their physicians and add comments. The main problem is that physicians can not defend themselves on these sites without breaching patient confidentiality. How is it fair for someone to provide a one-sided statement that usually is derogatory toward the physician or practice and we can not refute the claims by giving our side of the story. Who can make an informed decision based on one person’s claim of being treated poorly or unfairly?

There is always another side to the story! What is not being told is that the disgruntled patient may have wanted something that violated policy, the physician’s license, or the medical practice act. Perhaps the patient was abusive toward staff and was discharged? Maybe the patient just didn’t want to pay their bill and became upset that the practice sent him to collection? I can definitely say we have had our share of demanding patients who “want what they want when they want it”, otherwise known as the Burger King mentality. They do not want to go along with our rules and policies. They dont care that it was against the medical practice act to provide a prescription for something that the physician never treated them for.

I believe that anybody who looks at these rating websites really take it with a grain of salt. More often than not, satisfied people rarely go out of their way to find one of these sites and give their feedback. The patients who are fired up to get revenge are the ones that frequent these sites on a regular basis. Just think about how many patients a physician has and if you go to one of these rating websites and see 2 or 3 negative comments, is that really bad? Can you trust everything someone else tells you? What is their motive? Did that person have any part of the conflict? Have you ever met someone that was adamant that they were right about something and would not have an open mind to accept anything beyond what they believed?