- Determining how complex a patient interaction is is incredibly difficult. Most doctors are happy if they can guess 50% of the codes correctly. This link is a classic example of the problem. It gives 6 examples of patient visits to try and code. Even the expert coders could only agree on how to code two of them, and there is a disclaimer at the end stating that third party payers (i.e. insurances) may not accept the coding advice listed in the article anyway. The convoluted and inconsistent system of requirements results in continuous confusion by physicians as to how much they should bill the insurance companies, and has spawned an entire industry dedicated trying to helping doctors “code appropriately” so they can simply get paid for the services they provide.
In our office, we have a computer program that helps develop the office note with the different aspects of the billing requirements in mind, so visits are coded with a much higher degree of consistency and accuracy than can be done with a paper chart. But even doing it this way has the potential of failing if an insurance auditor does not agree with the computer, so we are left to essentially guess as scientifically as possible what the code might be and hope for the best.
- Even if the appropriate codes are submitted, all insurances reimburse different amounts and virtually no one pays the actual billed fee. This is called their “allowable” or “negotiated rate” and it is different for every insurance company.
Imagine if you managed a fast food store and you had twenty cars lined up in the drive thru. As the cars pass through, each pays a fraction of the listed cost for the hamburger and each one pays a different rate (say anywhere from 50-95 cents for the one dollar hamburger). Confusion would abound and trying to manage the store would be impossible as predicting future income would depend on which car came at which time, or how many of one car you have vs. another.
As you can imagine, this type of reimbursement system leads to discrimination based on insurance type. Those with high reimbursing insurances (usually PPOs) get lots of doctors willing to do anything for them, but the other patients (usually with HMOs, Medicare, Medicaid or no insurance at all) frequently have to look long and hard before finding a doctor willing take them as a patient. Although The Village Doctor has tried to remain idealistic and not discriminate based on a patient’s insurance, no practice can survive if it is too top heavy with low reimbursing insurances, so we are currently closed to all new HMO and Medicaid patients.
- Copays and deductibles make the system even more confusing. Even if Dr Brady was certain of the visit code and how much the allowable was for the insurance company, he would still have no idea how much the patient (vs. the insurance company) owes. Medicare is a great example of how confusing this can be. The first $110 dollars/year is considered the yearly deductible. After that, Medicare pays 80% of the allowable and the rest is either up to the patient or their secondary insurance to cover. Sometimes the secondary pays the deductible and the copay without problem, sometimes they don’t pay the deductible, but pay the copay, and sometimes they have their own deductible that has to be reached before paying anything (meaning the bill still has to be submitted to them so it can be denied and passed on in its entirety to the patient). What this system creates is continuous confusion over who owes what and a delay of up to 3 months (and sometimes billing 3 different entities) just to receive payment for a single office visit.
 |
Reimbursement Blues
Dr. Brady does all the medical billing for the Village Doctor, and it remains the most frustrating part of the practice. He could outsource the billing, but at a cost of 10% of all collections it would eat up a little over one month’s revenue per year, and would really push the practice toward not being able to maintain the service (same day appointments, 20 minute appointments) our patients deserve. Here are the problems with the current system of reimbursement:
|
|
|