Billing pitfalls
Yesterday I gave an example of a simple office visit and the requirements for payment. Today, I want to give examples of the “games” Insurance companies play to avoid paying.
Bundling:
This is where insurance companies will attempt to avoid paying for a particular service or procedure by stating it is included in the office visit.
· The example from yesterday was a urinary tract infection. Several insurance companies will deny payment for the Urinalysis and state it is part of the routine visit and is included in the fee of the visit.
· They also will try and do this with CBC’s, EKG’s and vision screens routinely.
Each one of these procedures requires extra equipment, supplies, reagents, technician or nurse time and is separate from a routine office visit. In some cases, the diagnosis cannot be made without these additional tests. Our Coulter machine that performs our CBC’s cost $15,000 and every individual test has a direct cost related to reagents and supplies besides technician time.
If the patient was evaluated in the office and given an order to go to the hospital and have these same tests done, the insurance company would pay without question, but since it is done in our office at the time of the visit, they try to avoid paying.
Allergy shots:
Patients can come in for an allergy shot alone any day of the week and the insurance companies pay for the shots. But if a patient comes in for an office visit to check up on their Diabetes, Blood Pressure etc. we cannot give them their allergy shot on the same day because the insurance company will not pay us for the shot. This means we either give them the shot and do not get paid for it or the patient has to come back on a different day. Neither of these are legitimate from our standpoint.
Annual Female exams:
We also have problems when women come in for their annual Pap Smears and exams. Some insurance companies will not pay for the cost of the Pap smear if we use an office visit code for a routine physical. They claim this code includes the Pap smear. But this same code is used also in men and we certainly don’t do Paps on them. The Pap smear also takes extra equipment, supplies and the specimen has to be sent out for interpretation which we are billed for.
Consults:
If we are consulted to see a patient at the hospital for a specific reason, we bill for a consult fee. If we then order an EKG or other test that we have to interpret or read on the same day as the consult, insurance companies will many times deny this interpretation fee because they state it was included in the consult fee for that day. If we were to interpret do the procedure on a separate day from the consult, they would pay.
Surgeons:
Surgeons have many problems as well. If they attempt to do more than 1 procedure at the same time or on the same day, they get penalized. The first procedure is paid at the accepted charge, the second procedure get paid at 50% and the third procedure at 30%. Procedures after that are virtually not paid for.
· An example is the hand surgeons who have to reattach 4 fingers. It takes the same amount of time, work, precision and responsibility to reattach the second, third and fourth fingers, but the insurance company will not pay the same. You certainly cannot bring the patient back 4 days in a row to reattach the fingers, but it isn’t fair from the billing standpoint. Anytime a physician performs more than one procedure at a time, they are penalized, even though doing these would ultimately save money and reduce patient risk.
These are a few of the billing issues we deal with every day. I cannot think of many other service oriented jobs that are able to do similar things. My auto mechanic can do multiple procedures on my car and I get billed for each. Plumbers, electricians, beauticians, lawyers etc. can all perform multiple tasks for clients and bill and be expected payment for each.
The medical system is broke and needs an overhaul!
Bundling:
This is where insurance companies will attempt to avoid paying for a particular service or procedure by stating it is included in the office visit.
· The example from yesterday was a urinary tract infection. Several insurance companies will deny payment for the Urinalysis and state it is part of the routine visit and is included in the fee of the visit.
· They also will try and do this with CBC’s, EKG’s and vision screens routinely.
Each one of these procedures requires extra equipment, supplies, reagents, technician or nurse time and is separate from a routine office visit. In some cases, the diagnosis cannot be made without these additional tests. Our Coulter machine that performs our CBC’s cost $15,000 and every individual test has a direct cost related to reagents and supplies besides technician time.
If the patient was evaluated in the office and given an order to go to the hospital and have these same tests done, the insurance company would pay without question, but since it is done in our office at the time of the visit, they try to avoid paying.
Allergy shots:
Patients can come in for an allergy shot alone any day of the week and the insurance companies pay for the shots. But if a patient comes in for an office visit to check up on their Diabetes, Blood Pressure etc. we cannot give them their allergy shot on the same day because the insurance company will not pay us for the shot. This means we either give them the shot and do not get paid for it or the patient has to come back on a different day. Neither of these are legitimate from our standpoint.
Annual Female exams:
We also have problems when women come in for their annual Pap Smears and exams. Some insurance companies will not pay for the cost of the Pap smear if we use an office visit code for a routine physical. They claim this code includes the Pap smear. But this same code is used also in men and we certainly don’t do Paps on them. The Pap smear also takes extra equipment, supplies and the specimen has to be sent out for interpretation which we are billed for.
Consults:
If we are consulted to see a patient at the hospital for a specific reason, we bill for a consult fee. If we then order an EKG or other test that we have to interpret or read on the same day as the consult, insurance companies will many times deny this interpretation fee because they state it was included in the consult fee for that day. If we were to interpret do the procedure on a separate day from the consult, they would pay.
Surgeons:
Surgeons have many problems as well. If they attempt to do more than 1 procedure at the same time or on the same day, they get penalized. The first procedure is paid at the accepted charge, the second procedure get paid at 50% and the third procedure at 30%. Procedures after that are virtually not paid for.
· An example is the hand surgeons who have to reattach 4 fingers. It takes the same amount of time, work, precision and responsibility to reattach the second, third and fourth fingers, but the insurance company will not pay the same. You certainly cannot bring the patient back 4 days in a row to reattach the fingers, but it isn’t fair from the billing standpoint. Anytime a physician performs more than one procedure at a time, they are penalized, even though doing these would ultimately save money and reduce patient risk.
These are a few of the billing issues we deal with every day. I cannot think of many other service oriented jobs that are able to do similar things. My auto mechanic can do multiple procedures on my car and I get billed for each. Plumbers, electricians, beauticians, lawyers etc. can all perform multiple tasks for clients and bill and be expected payment for each.
The medical system is broke and needs an overhaul!
posted by Anonymous at 6:01 AM
1 Comments:
Thanks, I also have the same problems. We like to give penicillan shots for strep throat, but the insurance won't even pay us enough to cover the cost of just the shot.
We still give them for convenience and we feel it is the best treatment and we just end up taking less for the office visit.
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