As you may know, Anthem Blue Cross and Blue Shield in Ohio is blending 99213 and 99214 codes into a single rate. This is a chilling trend that must be stopped.
As physicians adopt EHRs, documentation and patient care is going to improve – necessitating a proper reimbursement rate. Use of EHRs should be rewarded, not penalized:
“Before my EHR, I wrote on a piece of paper,” he says. “When somebody came in who was diabetic, hyperlipidemic, and hypertensive, it was extremely difficult to document everything I said and did.“The EHR allows me to do that. But now, Anthem says, ‘Oh gosh, now that you’re coding appropriately, we’re going to pay you less.’ So they’ve arbitrarily changed the rules. They make no differentiation between someone who comes in with a sore throat and someone who comes in with multiple medical problems that require fairly intense management, because they’re paying the same for both.”
Of course, the blended rate is much closer to the lower code:
It’s the difference between a $74.20 payment [for 99214] and a $51.58 payment [for 99213], and they’re paying us $55 for the in-between code. If you have someone with high blood pressure, diabetes, and high cholesterol, and you address all those issues, it’s worth more than $55.
Although confined only to Ohio, this can easily spread nationwide if there is no protest:
“However, if there’s no big uprising and no voice against it, that could change in a year or so,” he observes. “That’s why we think it’s vital that we make our voice heard in opposition to this kind of payment policy. It goes against CPT, and that’s what we base our billing on. If the plans make this change, we’re going to have a lot of problems.”
I encourage every physician to protest this code extortion by writing to the medical director at Anthem:
Barry C. Malinowski, M.D.
Medical Director
Anthem Blue Cross Blue Shield
Southern Ohio Health Service Area
4361 Irwin Simpson Road
Mason, OH 45040
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- Get ready for the ICD-10 codes
- Malpractice settlements: "A legalized form of extortion"
- Dancing P waves
{ 4 comments }
So much for “The Cognitive Physician” concept of a few years ago.
In a health care system dominated by federal policy, what ever gave you guys the impression that they wouldn’t change the rules – when it became convenient to do so – for their own purposes.
You can write all of the letters you want. Good luck.
Here’s a plan – see if you can get all of the PCP’s to collectively ‘not bill’ for the procedure. Instead – tell the patient they owe you $40 for the visit and put it in an ‘Escrow account” to be returned at a later date – then let THEM write the letters. That’s how you show your power.
The reason why it won’t happen is because most doctors put their comfort levels ahead of the necessary amout of ‘Civil disobedience’ required to turn things around.
Please don’t start writing a million blogs criticising me for writing this. Instead – write to one another in order to figure out how you can stop this trend. I’m trying to help.
Better yet, dump that plan and any others that “blend” their coding. Effectively they are paying a fixed and lower flat rate for comprehensive visits and are telling the doctors that they couldn’t care less what the record shows or how well it supports the higher coding. The sad truth is, if an insurance company decided to reimburse everyone and everything at a level two established patient rate, and gave notice as per their agreements, there isn’t anything you could do about it.
Forget escrow. Forget letters. Insurance companies understand only one thing: employers and subscribers who drop their coverage. That only happens when the purchasers of the “coverage” discover no one willing to take their cards at the desk.
Doctors aren’t the ones buying the plans (except for their office staff) Patients have to see themselves as the subscribers and assume the responsibility for insisting that the companies they pay for insurance coverage actually deliver.
The most important word that can be used in negotiation, especially with health insurers, is “NO.” As in, no, thank you, we will no longer see your patients; no, thank you, we have no interest in this contract until the contract is changed; no, Mrs. Jones, I can no longer see you because your insurance company is perpetrating fraud.
Unfortunately, saying “no” puts one out on a limb, and makes us worried that we cannot continue to make a living — and we worry that someba\ody else will say “yes.” So be it — it is better to ensure your practice’s financial stability than to worry that a competitor will get that business.
The only answer is tort reform. Off to the state and federal capitols with all of you!
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