This morning a United Healthcare representative came to my clinic to review patient charts and charges. "Auditing," it's called. "Intimiidating" is how it feels. She will send us a report informing us how we have fallen short in our documentation of patient visits, and what "action" the company will take to recover payments for services we provided.
Often the action is to "recuperate" money by sending us a bill demanding payment (to compensate for "overpayment" to us), or the insurance company withholds future payments for unrelated patients until it has taken back all it wants. Or our office is placed on surveillance by the insurance company, meaning they will delay all payments for months while they go through a process of rejecting claims, requesting paper copies of charts to confirm the patient in fact received the services we billed, and looking for areas of "under-documentation" that could excuse them from paying at all. Not being able to read a signature on a page is cause for refusing to pay. Not understanding the connection between a patient's fatigue and a chest x-ray or HIV test is enough for the company to deny payment. Doing a urinalysis without a note saying the patient complained of urinary pain could be cause for an accusation of fraud.
If a patient refuses to pay the insurance premium, complaining that the insurance carrier isn't paying his doctor, the patient's insurance coverage is terminated.
All insurance companies do this as part of their strategy to save money on doctors. While insurance companies refuse to pay, implying that doctors are not providing acceptable services, doctors keep seeing patients day after day.
The doctors are baffled. They think they must be doing something wrong. But they aren't. The insurance companies are corrupt.
If you bought a box of Cap'n Crunch and ate most of it, but counted out 4,324 pieces as you went and you wanted 4,325...or if the number of grams of fat in the box wasn't what you had mandated, or if for lack of training you couldn't understand the description of the product--would you be able to get your money back? Would you be able to get lots of boxes of Cap'n Crunch from now on to make up for your disappointment? Could you change your expectations at random, in a thousand-page document, and accuse the company of fraud if it didn't change its product immediately? Could you use a trumped-up allegation of fraud as a reason for banning the producer from selling it to all the people who want it? Could you refuse to pay whenever you wanted, and still expect lots of Cap'n Crunch to be on the shelf day after day?
Could you decide on the recipe for the product, and the price, and the people who get to buy it, and the places it's available, and whether or not you should have to pay for it on a case-by-case basis?
Doctors' expertise is being treated like that box of Cap'n Crunch. Patients want it, but their insurance companies decide whether they need it, what they get, and when--if at all--it should be paid for.
It's fine for the medical profession to be policed, but not if the police have a vested interest in stealing goods and inventing rules to allow them to continuing to steal.
Last week a Medicaid representative spent a few hours at my clinic doing an audit. Her reprimand, for which I am now "on probation," consisted of telling me that we hadn't been calling the new Medicaid patients assigned to us (patients who had not called or requested a visit) at least twice to schedule them for preventive health visits. Apparently this is a new requirement not yet listed in Medicaid's 10,000-plus page "Guidelines" for physicians. We are supposed to keep up with all of Medicaid's guidelines regarding coverage...even if they're not yet in print.
Medicaid's rules differ significantly from those of Medicare. And Medicare's rules differ from those of Blue Cross. Blue Cross has more than sixty different insurance plans in Florida alone, and each one has different coverage rules. Aetna, Tricare, Cigna, Av-Med, Prestige, Healthy Kids...all the different insurance "carriers" have many subsidiary "plans," each with its own rules--which change from month to month. Neither patients nor doctors can keep them straight. If my billing employees are able to reach insurance company representatives, they get widely varying interpretations of the "guidelines." The insurance company's employees also seem to find their rules arbitrary and unnavigable. Is this a deliberate attempt on the part of head honchos to confound physician offices? If the rules are many, varied, complex and constantly changing then insurance companies always have a pretext for refusing to pay.
Colasante Clinic takes more than twenty different types of insurance, all of which have a multitude of "options" with irrational coverage limitations. Therefore we manage hundreds of "plans" for patients. Some will pay for physical therapy, others will not; some cover a dietician, others do not; some allow a HgbA1c in the office, others require it be sent to an outside lab; some cover preventive visits, others don't; some limit how much can be spent per year, or how many visits a patient can have. Each patient has a different deductible to pay before the insurance company starts paying, and a different co-pay. There is no consistency across plans or within parent insurance companies.
Medicaid, a state insurance carrier for low-income patients, has never covered yearly preventive physicals for adults. That's why I was confused by the Medicaid auditor's criticism of our clinic.
"Medicaid doesn't pay for yearly preventive health visits on patients over age 21," I informed the auditor. "Why would we call to schedule people who have never been here before, for a visit Medicaid doesn't cover?"
"Well, it will now pay for those visits," said the representative
"But the Medicaid website clearly states that preventive visits are not a covered service."
"They will be covered when you submit them from now on."
"Is it suddenly on the website?" I asked?
"I don't know," she stammered.
"Well, I do know," I told her, not concealing my sarcasm. "Because I've memorized your website. All 10,000 pages of it. And preventive visits are not covered."
"All I can tell you..." she answered with stiff politeness, "is that it's a violation of our policy for your office not to have contacted these patients at least twice to schedule a preventive visit."
"Is Medicaid going to update its website to say this?" I asked, hoping to have recourse if my claims for doing yearly physicals should come back unpaid.
"I don't know," she answered testily.
"Don't you think if these new Medicaid patients want a visit they will call us? Why is Medicaid requiring that we solicit them?" I persisted.
"It's a new Medicaid requirement. It may not be listed in the manual yet, but it's your job to know and comply," she answered with her head held high.
Then she toured the clinic to make sure our procedure manuals and quality control measures were in place.
On her way out I asked, "What exactly is a Medicaid physical?" (Could it be different from the physicals I already did on every patient?)
"It's on the website," she said tersely, and left without saying good-bye.
It was wrong to treat the Medicaid auditor with rudeness. She's just "the messenger." But for whom is she the messenger? Isn't it the rest of us, you and I, who pay taxes that end up in the Medicaid coffers? Medicaid and Medicare are government insurance plans. They are funded by taxpayers. Their representatives should be answerable to us, not just the other way around. We doctors tiptoe around insurance companies as though they're the Big Bad Wolf. Why?
I have dozens of charts with insurance letters on my desk for Humana patients. Humana is asking for proof that I "definitely" saw these patients. (Are so many doctors lying about seeing patients that insurance companies need to audit us all the time?) They want hard copies of all documentation in the charts for numerous dates of service. They have not paid for these services, some of which go back many months. Humana audits us routinely. So do most other insurance companies.
This week Medicare sent me a form letter showing that because I bill 5.7% of all my Medicare patient visits as "moderate complexity" (99214) charges, and the "average" for the country is 3.1%, I am an "outlier." Therefore I will be "on review" until I come into compliance with my fellow physicians. It doesn't matter that, unlike most family doctors, my office provides a wide array of services on-site. Averages are averages.
If I am lucky enough to receive payments from Medicare for patients I have treated it will only be after (a) my claims have been electronically rejected; (b) a letter is sent to me requesting records; (c) the paper records are received within thirty days (if not, my loss); (d) an auditor at Medicare reviews the records within 45 days; and (e) a "determination" is made as to whether my clinic's services are "payable." The time-frame for all this is about five months, and there is no certainty whatsoever that any of my work will, finally, be paid.
Despite copious handwritten notes containing all "bullet items" for the sections of the history and physical and the "decision-making process" required in the office notes for all Medicare patient visits, and despite our written justification for everything we do, more than 80% of my office services have not been paid by Medicare in the past year. We receive electronic denials of payment with nothing more than the recent notice about my "outlier" status--which feels a bit like an accusation. If I telephone Medicare or Medicaid it's like...well, have you tried calling your phone company, or the IRS? Multiply the difficulty by ten.
Maybe the federal government has told Medicare not to pay me. After all, the FBI and other federal agencies have "inter-agency communications," my lawyer told me. When I asked what that meant he said, "They help one another."
I don't think there are "people" behind the auditors. There are only computer-driven algorithms ferreting out doctors who deviate from the national average, punishing them by withholding payments, and ultimately lowering the "national average." This works well to enhance insurance company "savings." It terrorizes doctors into doing very little. The effect is that patients end up being referred to specialists, or going to the emergency room, or going without diagnostic testing until their symptoms are extreme. Computers print out reports on doctors who see more patients or bill more per patient than the norm.
There are no grounds at all for assumptions of fraud in m office. Audits have proven, over an over, that--although I am an outlier--my patient care is thorough and exemplary. I am on probation with insurance companies simply because I do more for patients, and spend more time with them. It is illegal for the insurance companies not to pay, but they have ways around their own rules, and harassment of doctors pays off.
Auditors are clerks, not usually nurses, not people who have been schooled in the art of medicine or who understand the connection between coding and medical care. When I ask them specific questions about codes, such as, "Can a preventive visit be billed on the same day as an office visit?" or "Does your company require a -59 modifier on procedures like EKG's?" I am usually met with blank stares. They don't know the answers. They have been prepped to fulfill one mission, namely to find ways to "recuperate" money by censuring the doctor for illegible or inadequate documentation. If the office notes are in fact extensive, then the excuse for not paying is that the patient didn't "complain" enough to justify services.
Medicare has now placed my office on a "100% audit." This means that whatever I do for Medicare patients won't be paid until the claim is denied electronically, we receive a notice requesting records, and every applicable page is copied and mailed to Medicare. We have 30 days to do this, or we forfeit our right to be paid. Then Medicare has 45 days to respond--but they will take much longer.
Over the past year Medicare's electronic "decisions" have all been: "No documented medical necessity for this service." But there is documentation in the charts. To whom can I appeal? We have not been paid for flu shots (which are self-explanatory), laboratory tests, x-rays, EKG's, IV's, antibiotic shots...we've been paid for none of our ancillary services for Medicare patients in the past year. Everything done for patients in my clinic is supported by adequate--if not copious-- documentation. My letters requesting a phone or personal meeting with one of Medicare's many administrators have gone unanswered until one day last month. A single page said: "We will never meet with you. Our decisions are final."
Clearly my office has been blacklisted. Maybe it's "inter-agency cooperation" with the FBI. Maybe it's just business-as-usual for Medicare.
This is what solo doctors fear most: audits, refusals to pay, systems impossible to penetrate. To avoid what's happened to me most physicians under-code their visits, or hide out in template-driven electronic documentation. These systems produce terrible, uninformative office notes often using ten pages instead of one, but they give insurance auditors what they want: long lists of computer-speak. They do not further the patients' interests at all. They force doctors to spend time justifying treatments on paper, not actually treating patients.
Today my bookkeeper told me our bank account doesn't have enough money to cover the week's expenses. She says it's all being "held" by insurance companies who are "delaying payment."
So I guess the insurance companies win. And so does the FBI agent, Robert Murphy, who wanted to shut down my office last year, but didn't have cause. Now he doesn't need it.
Often the action is to "recuperate" money by sending us a bill demanding payment (to compensate for "overpayment" to us), or the insurance company withholds future payments for unrelated patients until it has taken back all it wants. Or our office is placed on surveillance by the insurance company, meaning they will delay all payments for months while they go through a process of rejecting claims, requesting paper copies of charts to confirm the patient in fact received the services we billed, and looking for areas of "under-documentation" that could excuse them from paying at all. Not being able to read a signature on a page is cause for refusing to pay. Not understanding the connection between a patient's fatigue and a chest x-ray or HIV test is enough for the company to deny payment. Doing a urinalysis without a note saying the patient complained of urinary pain could be cause for an accusation of fraud.
If a patient refuses to pay the insurance premium, complaining that the insurance carrier isn't paying his doctor, the patient's insurance coverage is terminated.
All insurance companies do this as part of their strategy to save money on doctors. While insurance companies refuse to pay, implying that doctors are not providing acceptable services, doctors keep seeing patients day after day.
The doctors are baffled. They think they must be doing something wrong. But they aren't. The insurance companies are corrupt.
If you bought a box of Cap'n Crunch and ate most of it, but counted out 4,324 pieces as you went and you wanted 4,325...or if the number of grams of fat in the box wasn't what you had mandated, or if for lack of training you couldn't understand the description of the product--would you be able to get your money back? Would you be able to get lots of boxes of Cap'n Crunch from now on to make up for your disappointment? Could you change your expectations at random, in a thousand-page document, and accuse the company of fraud if it didn't change its product immediately? Could you use a trumped-up allegation of fraud as a reason for banning the producer from selling it to all the people who want it? Could you refuse to pay whenever you wanted, and still expect lots of Cap'n Crunch to be on the shelf day after day?
Could you decide on the recipe for the product, and the price, and the people who get to buy it, and the places it's available, and whether or not you should have to pay for it on a case-by-case basis?
Doctors' expertise is being treated like that box of Cap'n Crunch. Patients want it, but their insurance companies decide whether they need it, what they get, and when--if at all--it should be paid for.
It's fine for the medical profession to be policed, but not if the police have a vested interest in stealing goods and inventing rules to allow them to continuing to steal.
Last week a Medicaid representative spent a few hours at my clinic doing an audit. Her reprimand, for which I am now "on probation," consisted of telling me that we hadn't been calling the new Medicaid patients assigned to us (patients who had not called or requested a visit) at least twice to schedule them for preventive health visits. Apparently this is a new requirement not yet listed in Medicaid's 10,000-plus page "Guidelines" for physicians. We are supposed to keep up with all of Medicaid's guidelines regarding coverage...even if they're not yet in print.
Medicaid's rules differ significantly from those of Medicare. And Medicare's rules differ from those of Blue Cross. Blue Cross has more than sixty different insurance plans in Florida alone, and each one has different coverage rules. Aetna, Tricare, Cigna, Av-Med, Prestige, Healthy Kids...all the different insurance "carriers" have many subsidiary "plans," each with its own rules--which change from month to month. Neither patients nor doctors can keep them straight. If my billing employees are able to reach insurance company representatives, they get widely varying interpretations of the "guidelines." The insurance company's employees also seem to find their rules arbitrary and unnavigable. Is this a deliberate attempt on the part of head honchos to confound physician offices? If the rules are many, varied, complex and constantly changing then insurance companies always have a pretext for refusing to pay.
Colasante Clinic takes more than twenty different types of insurance, all of which have a multitude of "options" with irrational coverage limitations. Therefore we manage hundreds of "plans" for patients. Some will pay for physical therapy, others will not; some cover a dietician, others do not; some allow a HgbA1c in the office, others require it be sent to an outside lab; some cover preventive visits, others don't; some limit how much can be spent per year, or how many visits a patient can have. Each patient has a different deductible to pay before the insurance company starts paying, and a different co-pay. There is no consistency across plans or within parent insurance companies.
Medicaid, a state insurance carrier for low-income patients, has never covered yearly preventive physicals for adults. That's why I was confused by the Medicaid auditor's criticism of our clinic.
"Medicaid doesn't pay for yearly preventive health visits on patients over age 21," I informed the auditor. "Why would we call to schedule people who have never been here before, for a visit Medicaid doesn't cover?"
"Well, it will now pay for those visits," said the representative
"But the Medicaid website clearly states that preventive visits are not a covered service."
"They will be covered when you submit them from now on."
"Is it suddenly on the website?" I asked?
"I don't know," she stammered.
"Well, I do know," I told her, not concealing my sarcasm. "Because I've memorized your website. All 10,000 pages of it. And preventive visits are not covered."
"All I can tell you..." she answered with stiff politeness, "is that it's a violation of our policy for your office not to have contacted these patients at least twice to schedule a preventive visit."
"Is Medicaid going to update its website to say this?" I asked, hoping to have recourse if my claims for doing yearly physicals should come back unpaid.
"I don't know," she answered testily.
"Don't you think if these new Medicaid patients want a visit they will call us? Why is Medicaid requiring that we solicit them?" I persisted.
"It's a new Medicaid requirement. It may not be listed in the manual yet, but it's your job to know and comply," she answered with her head held high.
Then she toured the clinic to make sure our procedure manuals and quality control measures were in place.
On her way out I asked, "What exactly is a Medicaid physical?" (Could it be different from the physicals I already did on every patient?)
"It's on the website," she said tersely, and left without saying good-bye.
It was wrong to treat the Medicaid auditor with rudeness. She's just "the messenger." But for whom is she the messenger? Isn't it the rest of us, you and I, who pay taxes that end up in the Medicaid coffers? Medicaid and Medicare are government insurance plans. They are funded by taxpayers. Their representatives should be answerable to us, not just the other way around. We doctors tiptoe around insurance companies as though they're the Big Bad Wolf. Why?
I have dozens of charts with insurance letters on my desk for Humana patients. Humana is asking for proof that I "definitely" saw these patients. (Are so many doctors lying about seeing patients that insurance companies need to audit us all the time?) They want hard copies of all documentation in the charts for numerous dates of service. They have not paid for these services, some of which go back many months. Humana audits us routinely. So do most other insurance companies.
This week Medicare sent me a form letter showing that because I bill 5.7% of all my Medicare patient visits as "moderate complexity" (99214) charges, and the "average" for the country is 3.1%, I am an "outlier." Therefore I will be "on review" until I come into compliance with my fellow physicians. It doesn't matter that, unlike most family doctors, my office provides a wide array of services on-site. Averages are averages.
If I am lucky enough to receive payments from Medicare for patients I have treated it will only be after (a) my claims have been electronically rejected; (b) a letter is sent to me requesting records; (c) the paper records are received within thirty days (if not, my loss); (d) an auditor at Medicare reviews the records within 45 days; and (e) a "determination" is made as to whether my clinic's services are "payable." The time-frame for all this is about five months, and there is no certainty whatsoever that any of my work will, finally, be paid.
Despite copious handwritten notes containing all "bullet items" for the sections of the history and physical and the "decision-making process" required in the office notes for all Medicare patient visits, and despite our written justification for everything we do, more than 80% of my office services have not been paid by Medicare in the past year. We receive electronic denials of payment with nothing more than the recent notice about my "outlier" status--which feels a bit like an accusation. If I telephone Medicare or Medicaid it's like...well, have you tried calling your phone company, or the IRS? Multiply the difficulty by ten.
Maybe the federal government has told Medicare not to pay me. After all, the FBI and other federal agencies have "inter-agency communications," my lawyer told me. When I asked what that meant he said, "They help one another."
I don't think there are "people" behind the auditors. There are only computer-driven algorithms ferreting out doctors who deviate from the national average, punishing them by withholding payments, and ultimately lowering the "national average." This works well to enhance insurance company "savings." It terrorizes doctors into doing very little. The effect is that patients end up being referred to specialists, or going to the emergency room, or going without diagnostic testing until their symptoms are extreme. Computers print out reports on doctors who see more patients or bill more per patient than the norm.
There are no grounds at all for assumptions of fraud in m office. Audits have proven, over an over, that--although I am an outlier--my patient care is thorough and exemplary. I am on probation with insurance companies simply because I do more for patients, and spend more time with them. It is illegal for the insurance companies not to pay, but they have ways around their own rules, and harassment of doctors pays off.
Auditors are clerks, not usually nurses, not people who have been schooled in the art of medicine or who understand the connection between coding and medical care. When I ask them specific questions about codes, such as, "Can a preventive visit be billed on the same day as an office visit?" or "Does your company require a -59 modifier on procedures like EKG's?" I am usually met with blank stares. They don't know the answers. They have been prepped to fulfill one mission, namely to find ways to "recuperate" money by censuring the doctor for illegible or inadequate documentation. If the office notes are in fact extensive, then the excuse for not paying is that the patient didn't "complain" enough to justify services.
Medicare has now placed my office on a "100% audit." This means that whatever I do for Medicare patients won't be paid until the claim is denied electronically, we receive a notice requesting records, and every applicable page is copied and mailed to Medicare. We have 30 days to do this, or we forfeit our right to be paid. Then Medicare has 45 days to respond--but they will take much longer.
Over the past year Medicare's electronic "decisions" have all been: "No documented medical necessity for this service." But there is documentation in the charts. To whom can I appeal? We have not been paid for flu shots (which are self-explanatory), laboratory tests, x-rays, EKG's, IV's, antibiotic shots...we've been paid for none of our ancillary services for Medicare patients in the past year. Everything done for patients in my clinic is supported by adequate--if not copious-- documentation. My letters requesting a phone or personal meeting with one of Medicare's many administrators have gone unanswered until one day last month. A single page said: "We will never meet with you. Our decisions are final."
Clearly my office has been blacklisted. Maybe it's "inter-agency cooperation" with the FBI. Maybe it's just business-as-usual for Medicare.
This is what solo doctors fear most: audits, refusals to pay, systems impossible to penetrate. To avoid what's happened to me most physicians under-code their visits, or hide out in template-driven electronic documentation. These systems produce terrible, uninformative office notes often using ten pages instead of one, but they give insurance auditors what they want: long lists of computer-speak. They do not further the patients' interests at all. They force doctors to spend time justifying treatments on paper, not actually treating patients.
Today my bookkeeper told me our bank account doesn't have enough money to cover the week's expenses. She says it's all being "held" by insurance companies who are "delaying payment."
So I guess the insurance companies win. And so does the FBI agent, Robert Murphy, who wanted to shut down my office last year, but didn't have cause. Now he doesn't need it.
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