FBI agents asked one of my employees if she had ever been asked to do "special projects."
I never used that language--which sounds like police jargon--but yes, she had.
I am about to do more "special projects." Therefore, I'd like to explain them in advance. They involve Medicaid, but they are not fundamentally different from the "special projects" about which the government took such an interest last year.
Medicaid keeps adding and subtracting codes to its library. I had neither known about nor billed several which apply to my practice. But the codes represent services that I have provided. Medicaid expects physicians to use them--or not get paid. The codes I just found out about are illustrative of a growing trend to pay primary care doctors for time spent with patients, and for specific kinds of counseling. Until recently, insurance companies have preferentially acknowledged hard services, like surgery, injections, EKG's, x-rays, IV's and physical therapy as "real" and payable commodities. But over the years the American Academy of Family Practice has lobbied hard for doctors to be paid for time spent with patients. One success came in 1997, when physicians were told that if they spent more than fifty percent of their time with patients talking about anything medical, the visit could be billed on the basis of counseling time rather than the physical exam and stuff done.
Since then, numerous codes representing time expenditures have been added to the coding manuals. These include time spent counseling patients for substance abuse (99408-9), past or present tobacco use (99406-7 replaced the older G0375-6)--treatment for tobacco use (S9075), and group tobacco education classes (S9453, 99078).
The codes I recently identified are 99401-99404--HIV counseling, and 99384-FP, 99386-FP, 99393-FP, 99394-FP, 99395-FP, 99396-FP, and 99403-FP--family planning counseling. Since these services may be billed retroactively for up to one year (for Medicaid patients; other insurance companies allow up to three years), I will review charts for patients who received counseling which is documented in the chart, and for whom the time I spent was not already included as part of the regular office visit. Therefore, Medicaid is going to receive from my office computer a sizable list of charges representing patient services not yet billed in the past year.
This may trigger an audit, but that's because insurance company computers are programmed to pick up "unusual" activity, a set-up designed to identify potential fraud. The fact is, any halfway intelligent person trying to commit fraud would carefully avoid billing activities such as the "special project" I'm about to commence. But I'm not trying to commit fraud, and I'm not trying to avoid looking as though I'm committing fraud. If Medicaid conducts an audit, it's fine with me. I have nothing to hide. Fear of an audit should not prevent me from transmitting correct charges for all the services I provided, even if they're almost a year late.
Physicians who don't keep up with codes like these, and who don't bill retroactively when they realize they've failed to send charges for which there is already documentation of a service in the chart, are cutting themselves out of significant, deserved, legitimate income. Maybe that's preferable to being targeted as an outlier, and enduring inspection, a raid and punishment such as that which I have described in this blog.
But if physicians keep trying to stay below the radar by undercoding or by declining to provide a wide array of services, or if we hide out in large groups (where the flack for coding falls on someone else's shoulders) the norm for what we really do in our clinics will continue to appear lower than it really is, and insurance companies will flag anyone who does more, bills more, and is paid more.
I never used that language--which sounds like police jargon--but yes, she had.
I am about to do more "special projects." Therefore, I'd like to explain them in advance. They involve Medicaid, but they are not fundamentally different from the "special projects" about which the government took such an interest last year.
Medicaid keeps adding and subtracting codes to its library. I had neither known about nor billed several which apply to my practice. But the codes represent services that I have provided. Medicaid expects physicians to use them--or not get paid. The codes I just found out about are illustrative of a growing trend to pay primary care doctors for time spent with patients, and for specific kinds of counseling. Until recently, insurance companies have preferentially acknowledged hard services, like surgery, injections, EKG's, x-rays, IV's and physical therapy as "real" and payable commodities. But over the years the American Academy of Family Practice has lobbied hard for doctors to be paid for time spent with patients. One success came in 1997, when physicians were told that if they spent more than fifty percent of their time with patients talking about anything medical, the visit could be billed on the basis of counseling time rather than the physical exam and stuff done.
Since then, numerous codes representing time expenditures have been added to the coding manuals. These include time spent counseling patients for substance abuse (99408-9), past or present tobacco use (99406-7 replaced the older G0375-6)--treatment for tobacco use (S9075), and group tobacco education classes (S9453, 99078).
The codes I recently identified are 99401-99404--HIV counseling, and 99384-FP, 99386-FP, 99393-FP, 99394-FP, 99395-FP, 99396-FP, and 99403-FP--family planning counseling. Since these services may be billed retroactively for up to one year (for Medicaid patients; other insurance companies allow up to three years), I will review charts for patients who received counseling which is documented in the chart, and for whom the time I spent was not already included as part of the regular office visit. Therefore, Medicaid is going to receive from my office computer a sizable list of charges representing patient services not yet billed in the past year.
This may trigger an audit, but that's because insurance company computers are programmed to pick up "unusual" activity, a set-up designed to identify potential fraud. The fact is, any halfway intelligent person trying to commit fraud would carefully avoid billing activities such as the "special project" I'm about to commence. But I'm not trying to commit fraud, and I'm not trying to avoid looking as though I'm committing fraud. If Medicaid conducts an audit, it's fine with me. I have nothing to hide. Fear of an audit should not prevent me from transmitting correct charges for all the services I provided, even if they're almost a year late.
Physicians who don't keep up with codes like these, and who don't bill retroactively when they realize they've failed to send charges for which there is already documentation of a service in the chart, are cutting themselves out of significant, deserved, legitimate income. Maybe that's preferable to being targeted as an outlier, and enduring inspection, a raid and punishment such as that which I have described in this blog.
But if physicians keep trying to stay below the radar by undercoding or by declining to provide a wide array of services, or if we hide out in large groups (where the flack for coding falls on someone else's shoulders) the norm for what we really do in our clinics will continue to appear lower than it really is, and insurance companies will flag anyone who does more, bills more, and is paid more.
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