Disclaimer: I am not a lawyer, I do not provide legal advice. Names, whether real or not are coincidental.
Yalaha, Florida, a small village in Central Florida has five (5) pediatricians. Drs. A, B, C, D, and E.
All 5 doctors see patients in their office which is located in the local medical building. Most of their patients have ABC Insurance which is an HMO.
Drs A, B, C, and D submit claims to ABC where the visits are coded no higher than 99203 or 99213. The charge submitted by each doctor is $19.95, the payment they get from ABC insurance for 99203 or 99213.
Dr. E submits the claim using the correct visit code, 99204, 99205, 99214, or 99215. The charge for 99204 or 9921414 is $125 and the charge for 99205/99215 is $225.
ABC insurance pays Dr E, $19.95 stating that the payment is usual and customary for pediatricians in his geographical area. ABC insurance sends Dr. E, a letter saying that his 99204,99214, 99205 and 99215 claims exceed the codes submitted by pediatricians in his geogrphical area. All of Dr Es claims are now pended for review. ABC insurance demands a refund of $25,000 for overpaid claims going back 10 years.
Drs A, B, C, and D submitted no claims with an E/M above 99203. They did this because they didnt wish to key an audit with their claims. Their charges were exactly what ABC paid. They did this as a shortcut so they didnt have to do adjustments in their software program.
By doing this, Drs A, B, C, and D established a geographical profile for pediatricians in Yalaha. Even though Dr E submitted his claims using the correct CPT code, it caused flags to raise when he submitted 99204, 99214, 99205 and 99215 claims. Dr Es patients were informed that Dr Es charges were too high inciting anger by Dr Es patients. When ABC wanted Dr E to be contracted with them, all ABC insurance said they pay pediatricians is $19.95, so, as a result. Dr E was not able to be reimbursed a decent fee for his services.
Today, a doctor contacted me because an insurance company has told him his office visits were higher than other doctors of his specialty in his area. They also demanded the return of his claims payments and he hasnt been paid on his claims in 4 months because they are pended for review.
Was Doctors A thru D wrong with submitting claims less than level 4 or 5? What they did could be called downcoding which is just as bad as upcoding. It could also be said that their claim wasnt 100% true, accurate and correct. While ABC may have felt comfortable paying a level 3 visit versus a level 4 or 5 visit. What was coded and reported wasnt correct. Setting their charges at just what ABC paid, may have hurt them when they wanted to increase their charges due to cost of living increases, ABC may deny their increase and getting a reasonble contract reimbursement could also hurt the practice. ABC profiled based on what they received and it was disservice to other providers in the same specialty in the geographic area. Dr E did what was correct and paid for it in more than money. It disrupted the patient-provider relationship. Dr E's patient may leave him for Doctors A, B, C, and D. The fees set by these other doctors may cause an investigation by Federal Regulators if a patient with governmental insurance or if ABC insurance signs governmental contract to provide HMO services to Medicare patients. self refers to these other doctors based on their lower charges. Could this open Drs A through D to a lawsuit by Dr E? It might be possible. If Dr E loses his patients along with his normal income, he may have to close his practice, and if he closes, his patients lose even though Drs A through D may take them on as patients. THis might not stop ABC insurance from performing claims audits for possible fraud and Abuse. ABC finds that the claims were downcoded, causing a fraud investigation,. The $19.95 that ABC paid is taken back on all fraud claims going back 10 years. The winner? ABC Insurance? The losers? Doctors A through E and their patients. Dr E is penalized because of Drs A through D not wanting to key an audit or to do adjustments. ABC used flawed or incorrect data to profile Dr E. To protect himself, Dr E has to spend time and money answering to the flawed data. When we submit claims, we do so, selecting the proper code based on the documentation of the service rendered and current coding guidelines. The claim must be 100% true, accurate and correct. The charges should be usual and customary and what the doctor would normally charge anyone for the service. This means Patient A who is uninsured, Patient B with Medicare, Patient C with Blue Cross and Blue Shield, and Patient D with Medicaid are all charged the same amount for the service. In other words. a 99203 my have a fee of $125, so the $125 is what is charged to the patient's insurance. If ABC pays $19.95, we need to know if $19.95 is what is supposed to be paid based on the contract with the member or per the Medicare or Medicaid fee if Medicare or Medicaid. ABC's contract with Patient A may be required to pay $125 if the charge is $125. If they are supposed to pay $19.95 with the balance being paid by the patient, then the $105.05 is billed to the patient If the $19.95 is the medicare allowble and the patient owes nothing, the provider performs a Medicare adjustment as required by a par provider. Practices should use a report of adjustments so that the doctor can see, not only what was made per insurance company and what was lost as income. If we had a payment applied to the deductible and transferred to the patient for payment, and the patient refused to pay, so their account went to our debt collection agency., a report of this was provided to be used if ABC wanted us to be contracted. We can show our losses when they took our payment and transferred it to the patient. We used that to support special clauses into the contract and increase what the insurance was to pay as a contracted rate.
Yalaha, Florida, a small village in Central Florida has five (5) pediatricians. Drs. A, B, C, D, and E.
All 5 doctors see patients in their office which is located in the local medical building. Most of their patients have ABC Insurance which is an HMO.
Drs A, B, C, and D submit claims to ABC where the visits are coded no higher than 99203 or 99213. The charge submitted by each doctor is $19.95, the payment they get from ABC insurance for 99203 or 99213.
Dr. E submits the claim using the correct visit code, 99204, 99205, 99214, or 99215. The charge for 99204 or 9921414 is $125 and the charge for 99205/99215 is $225.
ABC insurance pays Dr E, $19.95 stating that the payment is usual and customary for pediatricians in his geographical area. ABC insurance sends Dr. E, a letter saying that his 99204,99214, 99205 and 99215 claims exceed the codes submitted by pediatricians in his geogrphical area. All of Dr Es claims are now pended for review. ABC insurance demands a refund of $25,000 for overpaid claims going back 10 years.
Drs A, B, C, and D submitted no claims with an E/M above 99203. They did this because they didnt wish to key an audit with their claims. Their charges were exactly what ABC paid. They did this as a shortcut so they didnt have to do adjustments in their software program.
By doing this, Drs A, B, C, and D established a geographical profile for pediatricians in Yalaha. Even though Dr E submitted his claims using the correct CPT code, it caused flags to raise when he submitted 99204, 99214, 99205 and 99215 claims. Dr Es patients were informed that Dr Es charges were too high inciting anger by Dr Es patients. When ABC wanted Dr E to be contracted with them, all ABC insurance said they pay pediatricians is $19.95, so, as a result. Dr E was not able to be reimbursed a decent fee for his services.
Today, a doctor contacted me because an insurance company has told him his office visits were higher than other doctors of his specialty in his area. They also demanded the return of his claims payments and he hasnt been paid on his claims in 4 months because they are pended for review.
Was Doctors A thru D wrong with submitting claims less than level 4 or 5? What they did could be called downcoding which is just as bad as upcoding. It could also be said that their claim wasnt 100% true, accurate and correct. While ABC may have felt comfortable paying a level 3 visit versus a level 4 or 5 visit. What was coded and reported wasnt correct. Setting their charges at just what ABC paid, may have hurt them when they wanted to increase their charges due to cost of living increases, ABC may deny their increase and getting a reasonble contract reimbursement could also hurt the practice. ABC profiled based on what they received and it was disservice to other providers in the same specialty in the geographic area. Dr E did what was correct and paid for it in more than money. It disrupted the patient-provider relationship. Dr E's patient may leave him for Doctors A, B, C, and D. The fees set by these other doctors may cause an investigation by Federal Regulators if a patient with governmental insurance or if ABC insurance signs governmental contract to provide HMO services to Medicare patients. self refers to these other doctors based on their lower charges. Could this open Drs A through D to a lawsuit by Dr E? It might be possible. If Dr E loses his patients along with his normal income, he may have to close his practice, and if he closes, his patients lose even though Drs A through D may take them on as patients. THis might not stop ABC insurance from performing claims audits for possible fraud and Abuse. ABC finds that the claims were downcoded, causing a fraud investigation,. The $19.95 that ABC paid is taken back on all fraud claims going back 10 years. The winner? ABC Insurance? The losers? Doctors A through E and their patients. Dr E is penalized because of Drs A through D not wanting to key an audit or to do adjustments. ABC used flawed or incorrect data to profile Dr E. To protect himself, Dr E has to spend time and money answering to the flawed data. When we submit claims, we do so, selecting the proper code based on the documentation of the service rendered and current coding guidelines. The claim must be 100% true, accurate and correct. The charges should be usual and customary and what the doctor would normally charge anyone for the service. This means Patient A who is uninsured, Patient B with Medicare, Patient C with Blue Cross and Blue Shield, and Patient D with Medicaid are all charged the same amount for the service. In other words. a 99203 my have a fee of $125, so the $125 is what is charged to the patient's insurance. If ABC pays $19.95, we need to know if $19.95 is what is supposed to be paid based on the contract with the member or per the Medicare or Medicaid fee if Medicare or Medicaid. ABC's contract with Patient A may be required to pay $125 if the charge is $125. If they are supposed to pay $19.95 with the balance being paid by the patient, then the $105.05 is billed to the patient If the $19.95 is the medicare allowble and the patient owes nothing, the provider performs a Medicare adjustment as required by a par provider. Practices should use a report of adjustments so that the doctor can see, not only what was made per insurance company and what was lost as income. If we had a payment applied to the deductible and transferred to the patient for payment, and the patient refused to pay, so their account went to our debt collection agency., a report of this was provided to be used if ABC wanted us to be contracted. We can show our losses when they took our payment and transferred it to the patient. We used that to support special clauses into the contract and increase what the insurance was to pay as a contracted rate.
