Home Forums Discussions General Discussion Honesty?

Patient: Put down that I am here because of a sore throat and runny nose.

Doctor: Do you have a sore throat and runny nose?

Patient: If you don't put that down, the insurance won't pay!

Doctor: Do you have a sore throat?

Patient: No.

Doctor: Do you have a runny nose?

Patient: No.

Doctor: Then I can't put that down. why are you here today?

Patient: For a yearly physical. Why can't you just put down a runny nose and sore throat like I told you to. Just do what I told you.

Doctor: That would be insurance fraud. I won' t do that. The plan you choose does not cover yearly physicals to keep your premium lower. That would be your out of pocket expense.

Patient: I don't care! Put it down!

Doctor: So, why did you tell me that you had symptoms you didn't have?

Patient: Because I'm honest!

"So endeth the lesson." Jimmy Moran, The Untouchables"

I assume that this patient's insurance did not cover annual preventive exams. We have run into this many times also.

Frank,

Another appropriate Malone quote from the movie: "Well, then, you've done your job. Go home and sleep well tonight."

John,

Amen Brother.

Thanks

Here is the opposite:
Patient: You have to bill this visit as my annual physical exam

Doctor: Well, a screening physical exam implies that you have no existing chronic problems which are being followed.

Patient: But if you don't code it as a physical, I will have to pay my deductible

Doctor: Well, if I code it as a simple physical then we cannot discuss your hypertension, diabetes or high cholesterol and you will have to make another appointment for that.

Patient: WTF?? I have never heard such a thing!!

Doctor: I am sorry you have not heard of this. It is clearly spelled out in your insurance company's definition of a screening physical. You can go to their website as I have and read the definition and just what a physical entails and does not entail.

Patient: So what? What's the difference to you?

Doctor: About 50 bucks

Patient: Well then I guess I will have to find me another physician!!

Doctor: I understand and approve of that decision. My services will now be available to others who respect me enough not to ask me to commit insurance fraud.

Patient slams door and leaves.

I love a PCP who stands up for their basic right to be paid for their services. And this is just the cheap, 50% of fair market value pay. That patient would have excreted a brick if they themselves had to pay your actual fee schedule because of a non-covered service. What is it with these patients asking (demanding)doctors to commit insurance fraud?

Well done Leslie!

Now you can wait for your medical board to contact because you treated the patient poorly. (Sarcasm)

Oh, Leslie, what company has a "screening physical."? We've never looked at specifically doing that. Or is that just what you call the routine physical (9939x, 9939x)?

oh, that's 9938X and 9939X

If you do a preventative and also discuss chronic/acute stuff why not do the 99395 or 99396 add a 25 modifier and then a 99212 or 99213, tell the patient this is how you are going to bill them. Often times this is what I will do and have added an additional 15 minutes for their annual time slot if they have chronic conditions. You get paid for what you do.

This is what we do if we address and issue. We try to avoid it though. the insurance companies that do pay for both E&Ms under this scenario (not all do, e.g., Empire BCBS does not) now only pay 1/2 of their standard "allowable" because checking them in and taking their vital signs is 1/2 of the work for the visit (hey, that's what the companies say). And you still have to tell the patient about the copay or deductible, because the dedcutible/copay/co-insurance will apply to that part of the visit. So in Leslie's example, if she does this, the Preventive will be covered by the company at 100%, but the acute illness will be covered as a regular E&M (with 1/2 the reimbursement) and the deductible, etc. will apply so you need to be sure to tell the patient that.

I have tried billing both preventive and problem oriented codes amd never get paid. UHC is the worst. The preventive codes pay about $50 less than a 99215. Anthem will bundle a problem oriented code, e.g. 99213, and a cryotherapy procedure and pay the lesser of the two. As a solo physician in a big market I have no negotiating power...they have literally laughed at me when I challenged them.

I think Empire BCBS is the worse. But they do come straight out and say they will not pay any problem-oriented E&M (99213) with a preventive exam. They only pay the preventive exam and actually put on the eob that the other is considered part of it. We tell the patients that they have to have a separate visit on a different day since their insurance won't cover both at the same time.

No, Tricare is the worst. That's why we only have 1 Tricare patient, this guy, my pastor:

Pt scheduled physical exam and medical problems appt with previsit labs
During the exam, addressed his HTN, Hyperlipidemia, Gout, Asthma and refilled his meds.
Also pre visit labs showed fasting glucose over 300, ordered and reviewed AIC, discussed his new diabetes, referred to dietician, started DM meds.
Pt says OBTW, could you freeze this wart? "Sure."
Submitted PE codes, E&M codes, Cryo to wart, with proper modifiers.

Tricare paid for the wart. They said everything else was "incident to.."

We laughed... They were not kidding.
Many phone calls, multiple resubmissions (with exactly the same, proper codes)
1 year later got a check for the original full amount. No explanation. No apology. No interest.

Unfortunately, none of the above stories are foreign to us.

Maybe the fiscal cliff will wake us up to better business decisions.

Dave
FP