The Hypocrisy of Overbilling
In the ER the difference between charging a 99284 and a 99285 is the addition of a family or social history (which can be as simple as "lives alone," or "nonsmoker," but not necessarily both). That one line is completely irrelevant to my medical decision-making, but increases my payment significantly. A similar situation occurs with inpatient admissions and consultations; if the useless family history is omitted, the physician's payment is reduced.
Is billing for questionably-indicated procedures really any different than adding an unnecessary family or social history to increase one's charges? I say no. If I don't need to use the social/family history in order to make an accurate diagnosis and disposition, then I'm essentially overcharging just the same as a Cardiologist who orders a questionably-necessary echocardiogram. We play these tricks because the government doesn't pay us what we think our services are worth.
The Happy Hospitalist sees it differently, and we are having an interesting discussion in his comment section. What say you?
Is billing for questionably-indicated procedures really any different than adding an unnecessary family or social history to increase one's charges? I say no. If I don't need to use the social/family history in order to make an accurate diagnosis and disposition, then I'm essentially overcharging just the same as a Cardiologist who orders a questionably-necessary echocardiogram. We play these tricks because the government doesn't pay us what we think our services are worth.
The Happy Hospitalist sees it differently, and we are having an interesting discussion in his comment section. What say you?
Labels: billing, links to greatness
posted by scalpel at 1:58 PM
37 Comments:
I see no hypocrisy. Viewed this way, 100% of the level five's in the ER are overbilled, since a "complete" review of systems is almost never truly necessary.
There is a distinction, I think, between these two practices:
1. Documenting required but arguably irrelevant information to maximize reimbursement in a legal and compliant manner.
2. Performing diagnostic tests or procedures on patients to increase reimbursement.
Implicit in #1 is the assumption that the rules are designed to inappropriately deny fair reimbursement by requiring irrelevant information. This is why I think it's OK to "game the system," since the system is unfair and hostile.
#2, however, is DOING something to someone, whether it's a benign thing like an extra ECG or a not-necessarily benign thing like a CT scan or angiogram. Unless it's really appropriate, that seems much more ethically problematic.
Ever been tempted to suture a marginal wound knowing that you'll get paid for it but you wouldn't for steri-strips? Slippery slope...
A Cardiologist might justifiably consider performing an ECHO as part of his evaluation, just as I might consider performing an ultrasound as part of my initial evaluation of a patient with abdominal pain. Just because the government makes us bill separately for them doesn't make performing them unethical.
My position is that it's not greedy doctors that are the problem, it's unreasonable government regulations that induce us to jump through hoops in order to get reimbursed adequately.
Shadowfax said, "...the rules are designed to inappropriately deny fair reimbursement by requiring irrelevant information." Looked at another way, Medicare/Medicaid wants to make certain you've done perhaps the most important medical procedure -- take a complete history -- and penalizes you by reducing your payment unless you prove you did.
Here's the response I just left over at Happy's place.
As a patient, I would like to know just how much the question "do you smoke?" actually costs me, especially if I've been asked it numerous times and the answer is always NO. If I'm paying a percentage (or full) cost of the exam, it certainly seems as frivolous as admitting me to the hospital for a 5-day IV steroid infusion to treat an MS flair when it could more easily be done as an outpatient.
If the family/social history has absolutely no bearing on the diagnosis and treatment protocol, in the same manner that being admitted for infusions which can be completed in under 2 hours daily may not be necessary, then I do believe they are equally inappropriate.
I document "noncontributory" in the social and family history sections a lot of the time and that seems to satisfy the requirements. And yes, I agree that is just plain stupid. The other thing is how you are not really paid to use your brain in medicine - the guy who PREVENTS someone from needing surgery by good medical management will never make as much as the guy who does the surgery to fix the problem.
Lisa: you don't have to tell us; we can just get that information from your previous records, or even just make it up.
Here's another example: say you stub your toe and come to the ER for evaluation (yes, people really do that). In the absence of a fracture, about the most we can reasonably bill from your insurance company is a level 3 charge, 99283: maybe $200, of which we will actually receive about $60.
In order to bill that level of care and receive that payment, we are required to document a medical history as well as the examination of 2 separate features of 6 different categories of body systems (such as our general impression and also examination of the heart, lungs, skin, psychiatric, and yes, even the actual injured toe itself.
Your vital signs have been reviewed, and you are in no distress. Your heart has not only a regular rate and rhythm, but no murmurs. Your lungs are clear to auscultation, and there are is no wheezing. Your are alert and oriented to person, place, and time (I personally skip this part because I hate asking those questions). Your concentration and insight appear to be normal. Your skin is warm and dry. And your toe is slightly tender to the touch with full range of motion and no bruising.
If we just document the toe exam, we can only bill for a level 1 visit, which only pays enough for a diet coke and a bag of chips, give or take. So we end up doing (or at least charting) a bunch of crap that we don't really need to do to make sure your toe is OK.
We use the Electronic T-system which is nice because when you go to lock out the chart it tells you what level you can bill for based on what you have documented. I often realise I forgot something (that was usually obvious like "no resp distress" under lung exam). I go back and check off that box and ola' level 5 (or three or whatever).
This makes my head spin. I just want to go sit in a corner and rock.
When will it end?
Since when are physicians so incompetent that they need a list of questions to help them do their jobs?
Amy, imagine owning your own massage parlor. Now, imagine you spent one hour with your client and charged them 100 dollars. Now imagine that your client handed you a card and said, here's $20. You get the rest of your fee from The Card Company. So you submit to the Card Company your bill for payment. The following is a list of the rules that the Card Company would require for you to get paid; take your pick, there are two sets of rules:
http://www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf
http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf
Now, as you have skillfully mastered your art of massage, you must now work under the constant threat of fraudulent activity if you don't memorize and accurately charge your client based exactly on what you document in your one hour of service, as applied to one of these sets of rules.
And this is only the rules to get paid.
I wont fault you for your ignorance on the rules and regulations if you don't fault a physician for being incompetent to need constant reminders on how to play the game.
Now, I consider you fully informed. Do you care to retract your statement?
The links aren't coming through:
Google "evaluation and management", 1997
That will get you the CMS documentation web page at the top for both 1995, and 1997.
So if family and social history aren't necessary, why are they beating it into my head in med school?!?!?!?!
I also have to be sure to ask "what do you think this may be?" and "what are you worried may be causing your symptoms?"
I checked my own e-chart at work once, and I'm a "single emergency department nurse who works rotating shifts and has one school-aged child".
And I thought my endocrinologist was just making small-talk. The rotating shifts aspect is important for diabetes management however. Since he helped me develop a plan for day shifts vs. night shifts, I hope he gets paid a little more because he tailored his management to me specifically vs. some generic person or cookbook medicine articles on diabetes.
If I said "I work 8 to 4:30 every day and never vary my routine" that means he probably doesn't have to address additional stuff, but at least he was looking for other stuff to address. To me, that's good medicine.
I think there are many social factors at play in the ER and at least some cursory thought in that direction is important for most problems. Even the guy with the simple cut finger might be uninsured and unwilling or unable to pay for keflex or whatever. I've even seen the doctors document that they referred the patient to Wal-Mart for their pills based on their 10-second social history. Sometimes they'll even do something like write the prescription and tell the patient only to fill it for signs of infection based on patient's "inability" to afford medications.
I'd like to know a situation where there is no possibility that social or family history is important.
Social/family history is rarely important in making a disposition. Oh, maybe if a patient had a REALLY strong family history of early MI that fact might push us to admit an otherwise atypical chest pain in a younger patient than we would usually admit. Or if an old woman with a borderline indication for admission happens to live alone, we might be more inclined to admit her.
We're not getting paid the difference between a level 4 and level 5 to counsel a patient about smoking cessation, or to plan their discharge more efficiently. We're just getting paid to fill in the checkbox. What we do with that information (if anything) is unpaid extra BS. Hey, don't blame me - I didn't design the payment schedules. "Good medicine" isn't reimbursed any more than shitty medicine. That's one of my complaints.
In an obvious admission like a STEMI, how does the fact that the patient smokes or lives with his wife change our management? In any true emergency that information is worthless to us, and in our haste to get the patient to the cath lab, the answer is probably faked (or "noncontributoried") as often as not.
"I wont fault you for your ignorance on the rules and regulations if you don't fault a physician for being incompetent to need constant reminders on how to play the game.
Now, I consider you fully informed. Do you care to retract your statement?"
Did you just call me ignorant?
What do you want me to retract? The part about rocking in the corner?
I haven't called any physicians incompetent. I was merely stating my frustration at the red tape and beaurocracy that get in the way of practicing medicine.
I can imagine only how frustrating it must be for doctors to go throught the years of training, not to mention expense, and then spend their careers mired in paperwork, dotting the i's and crossing the t's, when they'd much rather be out there doing what they were trained to do.
I am well aware at least from the standpoint of a consumer how insurance copays, contracts, and negotiations work. Although I appreciate the time you took to explain it to me with a fabulous homeopathic refrence so that it would be simple enough for my little brain to understand, it was unnecessary.
I did work in a lab for a bit in a very large hospital so I do have a bit of experience with jumping through the hoops so that the insurance compaines will reimburse the hospital for the services provided.
So what exactly makes me so stupid? Or you just trying to scare me away from commenting by calling me ignorant and speaking to me as if I'm a child. I did think this was a public forum and not a special club.
I love it when doctors talk down to me. It makes me hot.
You know Hospitalist, the more I read your angry response, the more I think we're on the same page here.
The insurance reimbursement hoops that have to be jumped through waste time and money. Call me naive, but I *don't* think that most doctors are out there to rip off their patients. I chose to believe that most doctors actually care about people and helping them. It is my ever so humble opinion, that doctors shouldn't have to prove what they have done like a bunch of kindergarteners to get paid for their work.
If only we could have a free market health system, things would be MUCH better for everyone. I will absolutely admit to being ignorant as to how we can transition our health system from where it is now to where it should be.
I suppose next time I'll insert fancy {sarcasm} brackets, or something. It doesn't translate well over the net.
It still bothers me that you called me ignorant. I can call myself dumb, but I don't like it when you do it.
Scalpel,
RE: STEMI -- don't forget that you can use the acuity caveat to excuse you from the ROS and PFSH requirements.
One minor quibble: I generally think the social history is very important in anticipating ER patients' needs upon DC -- are they a druggie, homeless, alcoholic, indigent, do they have financial and social support etc -- sure, a negative SH winds up being unhelpful, but it's often critical.
I would contend it's the "full ROS" that's a more ridiculous requirement. You see someone with chest pain, and you're going to be performing a Complex, High-risk service with lots of data to review and important decisions to make.
Whether they have dysuria is irrelevant to the presenting problem and it chaps my ass that I have to ask that question to get paid.
My position is that it's not greedy doctors that are the problem, it's unreasonable government regulations that induce us to jump through hoops in order to get reimbursed adequately.
Amen.
(Amy -- I missed the sarcasm too.)
"Social/family history is rarely important in making a disposition. Oh, maybe if a patient had a REALLY strong family history of early MI that fact might push us to admit an otherwise atypical chest pain in a younger patient than we would usually admit"
I also posted on happy hospitalist on the importance of fam/soc hx. Although fam/soc hx might not change your ultimate dispostion, I think in many cases it could influence your interaction with the patient. Even if you don't admit that young patient with atypical chest pain, knowing that there was a family hx of coronary artery disease may help you in effectively counseling him about the importance of following up with his outpt doc. Asking about fam/soc hx may not be that relevant to your style of practice, but I can honestly say that when I document these, it's not just to pad my bill.
I sometimes wonder about some of the questions and all.
I go in for my BCP prescription renewal.
Why do I get asked if I fasten my seatbelt? Every time? I do, but we waste time asking about the seat belt EVERY time? What, do you think I hit my mid-40s and thought, "hey, I know, I'll try to fly into the windshield next time there's an accident!")
And do they think I've hit my mid-40s and suddenly thought, "hey, I'll take up smoking this week?"
And the whole listen to the heart thing? Is that really useful for someone who sees the doctor once a year for birth control? (That's a real question: how often do you hear something really important on a patient with no symptoms?)
It seems weird to wait six weeks for an appointment, 45 minutes after my appointment time, and then spend time asking about my seat belt? Give me the renewal, and spend your time with people who don't feel well! (Including me when that comes to pass.)
We're just getting paid to fill in the checkbox. What we do with that information (if anything) is unpaid extra BS. Hey, don't blame me - I didn't design the payment schedules. "Good medicine" isn't reimbursed any more than shitty medicine. That's one of my complaints.
This is true, but good thing you have nurses meandering around to address the social issues when the doctors don't. Since I'm the one to ultimately give the discharge spiel at the end, I'm the one making many of these little suggestions like "here are two clinics which take people without insurance and their phone numbers" and whatever else. You can check the box and get paid a little more, and I'll take some of the burden off you to address what the box says.
Don't forget to ask if the patient has had all their vaccinations, whether they feel safe at home, if they have been physically abused, etc.
Wow, Scalpel, I had no idea how complicated this stuff gets. As a nurse, I chart key words so the insurance companies won’t deny a patient’s insurance claim. We are coached by nursing case managers to make sure our charting is “just right.” I didn't know that doctors are also involved in these types of acrobatics in ordered to get paid. I think you should do what ever is necessary to pay the bills.
"And do they think I've hit my mid-40s and suddenly thought, "hey, I'll take up smoking this week?""
anon 7:24, it's important to ask those taking bcp if they smoke, especially if they are over 35. The stroke risk goes up markedly with the combo of smoking/birth control pills/age >35. If you did take up smoking and your doc forgot to ask you about this, you could easily win a mega-lawsuit if you had a stroke while taking bcp.
Excellent points. There are admittedly specific situations where the smoking/drinking history is significant, as there are certain situations where the family history can be significant. In other presentations, such as the dialysis patient with hyperkalemia or the menorrhagic patient with severe anemia, for example, the inclusion of social or family history is done simply to maximize my charges.
Those conditions justify level 5 charges, but without including extraneous data, I can't bill as much as I am entitled to bill.
I imagine many specialists feel the same way about their bill-padding procedures of choice.
Needlessly documenting social history is harmless, free, quick, and of neutral significance to the patient.
Needlessly performing a procedure is far more time-consuming, expensive, often has the capacity to cause harm, and makes the patient believe that said procedure is necessary for diagnosis or treatment. So it is comparable to lying to the patient (which is unethical), is a waste of resources besides, and furthermore may cause unnecessary pain or result in unnecessary risk. So no, I don't think the two scenarios are comparable.
It's not free; the difference between a level 4 and a level 5 ER charge is about $100. It also often provides no useful information, whereas even a normal diagnostic procedure like an ECHO, colonoscopy, or nerve conduction study provides useful information..
i don't understand how you determine if something is done unnecessarily. just because you think it is unnecessary, does not mean it is unnecessary. likewise, people rely on different methods for detection of disease. one person may feel that auscultation is sufficient to rule out mitral valve prolapse. is a second opinion a waste? is the echocardiogram the second person ordered unnecessary since the first person didn't need it, even if the second one feels it is warranted?
yes there are some practitioners that are out there in terms of echos requested. maybe they are more exacting and want to make a specific diagnosis. maybe they follow things more carefully. maybe they believe dynamic left atrial size is an important feature in long term stroke risk, even though that is not guideline friendly. do you think the majority of people are performing unnecessary tests or that the ones who are out there just rely on different markers for diagnosis and management of disease?
the situation is still the same, TO ME, as long as there is some reasonable justification to the procedure/test.
do you need even vital signs for a 24 year old's stubbed toe? slippery slope. :)
anon 1200. I'm not saying something is done unnecessarily. The basis of this blog entry was because I had a specialist tell me flat out that some of his partners do studies for money. (see original entry on my blog). I don't have a problem with ordering tests. I order lots of test. But I have no financial interest in ordering them, since I don't interpret any of them. If anything, I order fewer tests, because I stop and think multiple times a day when I order something, if it will change my managment in any significant way. If it doesn't, I don't order it.
If you think money is a good reason to do a test, please disregard everything I have said.
Hi Dr. Scalpel. I've been reading your blog for a few months and I really like the stuff you talk about. Just commenting to let you know I'm here :)
to hh:
the point is that the individual does either a)not know for a fact that the partner is doing it for money only or b)they are a partner in committing fraud. why don't you ask them again and see what their answer is?
if you know them to be fraudulent, then you have an ethical duty to report them on your patients.
sure when asked if i think it is a bad thing when people do tests with no value whatsoever to a patient just for money, how can the answer be anything but of course it is a bad thing.
ps i could argue that you have a financial incentive to order tests. the hospital profits from them, and that is where your part of your salary is derived from, if you follow a traditional hospitalist model. if you are not receiving any funds from the hospital, that makes the argument a lot harder.
anon1235. I'm not quite sure why you are so distressed. I told you what I was told. As far as me having a financial incentive to order tests. That statement alone tells me that you can't possibly be in the medical field. If you are, you are not educated in the DRG payment system of medicine. Education is key.
I weighed in on this over on my blog, though I apologize for not perusing this comment trail first. Your Anon 05:41 said essentially the same as I.
to hh:
you are quite incorrect re: your financial impact in the hospital. the hospital most certainly does generate technical revenue from tests you order. why do you think you have to fill out all those indication bullets on your radiology forms? just leave them blank for a few days and see how long it takes for the hospital and radiologist to come howling.
certainly you are correct as far as the reimbursement being independent of los.
agreed that education is key. i assume you mean both of us.
anon 0917. Could you please show me your source of information that states hospitals can collect facility fees AND a DRG on an inpatient hospitalization. I would love to see it for myself. What I read clearly differentiate between the DRG weighted payment system of an in patient stay via the IPPS (inpatient prospective payment system), and the outpatient facility fee payment of ASC or other outpatient services. When I order an echo for a patient with an MI, the hospital collects a DRG for the MI. You are telling me it also collects a facility fee for the echo. I'm saying it doesn't. Please show me your reference.
I am the Billing Compliance Laison for my department, and this post makes me concerned.
Because you are absolutely right - routinely performing additonal but unnecessary components of the H&P to pad the chart is overbilling, and opens you up to potential climas of fraud from Medicare.
There are three componenets to the visit that must support the level of service you choose - the first two are the history and exam, and the third is medical decision making. In this case, the medical decision making does not support the need for the aditional exam components or the use of 99283 for a stubbed toe in an otherwise healthy patient.
But you are attacking the wrong part of the problem. The issue is not the coding. The issue is the reimbursement for these codes. Evaulating and treating a stubbed toe is worth lots more than a bag of chips and a coke. (At least a burger and fries....)
And very seriously, I would ask your compliance folks to come down and review your charts, I suspect you may be placing yourself at risk, both with this practice and with this post.
Now I just read your comments over at Happy Hospitalist and it's clear you know what you are doing and are just ranting.Strike last suggestion.
Have a burger and fries. On me.
Sorry, naive, but there's another component if anyone is still reading this (it's soooo old).
The risk v. benefit aspect. If someone orders unnecessary tests there is a larger risk than just asking a question, especially when we get into CT scans and CIN, for example.
I was taught my first week of EM that listening to the heart and lungs every time would substantially raise my billing. Is that illegal, listening to someone's heart and lungs? Also, very low risk.
I actually use the social history to give myself a bit of mental space in the room and to establish rapport with the patient. Granted, as a medical student, it takes me longer to think and I have four hours to work up my one patient, but still, it often works wonders if you ask them about their family or life.
I'm late to the party, but I wanted to mention that as someone who came out of an abusive home, it really makes me happy to hear how commonplace the screening questions for abuse are becoming in healthcare settings. My mom eventually got out on her own, took us kids with her, and probably saved all of our lives in the process. But there are many who never get out. Would my mom have done so sooner with screenings and information like this? No way to know, but it's hard to see it doing harm.
And if it saves even one family's worth of kids a month or six months or a year or a childhood of being choked and shaken by their necks and thrown headfirst into walls and having guns pointed at their heads because they are the cause of all of their family's problems and without them things would be better, then it's worth taking two seconds and asking the question of everyone.
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