Oh wait there is the other part of fraudlent billing that that happens. Where the doctor's office "accidentally" bills the patient for the PPO discount or the amount over the Medicare allowance that they are either contractually or legally obligated to write off.
Many older people just set up a payment plan and pay that billed amount because that is "their financial obligation". But, of course, if you call to ask the billing department at the doctor's office "Oops, that was a mistake". However there are plenty of doctors offices that it is their practice to bill over the Medicare allowance until they are called on it and then they just mark that patient's account to only bill to Medicare allowance.
I have been told by people in the medical field that at some medical seminars there are sessions on how to maximize revenues by upcoding and unbundling. So you saw the patient for 10 minutes bill for the 15-30 minute code instead. See same patient for a new complaint 6 months after last visit- call it a new patient visit.
In the EMR system my hospital uses (a very common EMR that dominates the market BTW), procedures, tests and certain other orders have to be associated with some code in order for the order to be processed. Some codes are for technical diagnoses (ie moderate asthma, chronic systolic heart failure, coronary artery disease), others are more for symptoms (chest pain, shortness of breath etc). It is completely byzantine and random which code will be accepted by the computer, especially in the situation where someone has symptoms but no actual diagnosis yet (that's why I'm ordering the #$*&! test!). I just want to get my patient the care they need, and not ponder what the difference is (to the computer system) between "chest pain," "angina" and "angina on exertion," and why one code is accepted and the other not.
I spent 4 years in college, 4 in med school, 5 getting a PhD and will do 6 years of residency/fellowship by the time it's all over (midway through residency currently). I'm not a stupid person and neither are my colleagues. There's something wrong when the system is so obscure that intelligent, educated, well-meaning (for the most part) professionals can't figure it out.
That is fraud. You cannot have been seen w/in three years in order to be a new patient, period. And your documentation supports or doesn't support the complexity level selected. Physicians don't get to just randomly state it's a level 5 visit w/o documentation.
Originally Posted by SonnysMom
Blueeyedsorrel, can I like your post about a million times? My hospital just went to EMR in the clinic this month, physician order entry and billing at the hospital to follow. I had a little break down in clinic this week that, to sum it up, basically ended up as I AM NOT A CODER, LET THE CODERS TO THEIR JOB AND ME DO MINE!!!!! I will give them the diagnosis, tell them what procedures I did and/or ordered, but let them do the formal codes and associations and other bs that goes along with it. You know, in my 4 yrs of college, 4 yrs of med school, and 4 yrs of residency and the time since then I have not had one class about coding, all I have had is here is a card that shows the levels, have fun! That is it, nothing else. So then I usually under bill most things, but that can be Medicare/ Medicaid fraud as well. Ugh. But please, people, I know things are messed up, but do not blame the doctors for everything. Most of us just want to take care of patients and hate this side of the world, and often times have little to do with it. (And with going to EMR (electronic medical records), I bet more mistakes are honestly happening now).
We just transitioned to an EMR as well...we all hate it, albeit the product our facilty chose is on the low end of things.
Lets be clear...not ALL phsyiciansand/or their billing offices are out to screw everyone. I work in billing and I get so TIRED of hearing how the Dr's and their billing offices are the ones screwing up healthcare. While a few may be entering fraudulant charges on purpose, most are not.
Accidents happen, just with anything else. Somestimes its because old sticky fingers put John Does charges on Jane Doe...sometimes its becuase the software used throws charges in when certian words or diagnosis are picked.
We have a charge entery person who is SUPPOSED to "scrub" all of the EMR claims before we send them out but yes, even she makes mistakes, more than she should, but thats another story.
And to whoever said something about billing a new PT office visit for a new DX 6 months later...it doesnt work like that.
So no, dont put all of the blame on the Dr OR the billing office...I am so sick and tired of being yelled at for crap that I have no control over.
FYI - it is very possible that the first set of xrays that you got at your primary care physician's office truly were not diagnostic quality; it's quite common for that to be the case when imaging is done in locations other than a radiology suite. Oh and although that PCP "read" your xray - this is not something that most PCPs are trained to do, so normally they need to have a physician who IS trained in that work (a radiologist) at least over read the film to make sure nothing has been missed. Billing for an xray that has not been interpreted by a radiologist can be quite problematic, in fact. (This is also true for orthopedists, who typically think they read films better than radiologists... even though they usually have not been trained to interpret images either.)
Originally Posted by pony4me
Unfortunately the whole coding/billing/payment component of our healthcare system is pretty screwed up at the moment (and this is not something that Obamacare is likely to fix.) Depending on the office in question, the coding is often done either by software programs that essentially look for key words or selections made by the MD or NP if they charted your visit electronically... or possibly by relatively low-paid billing/coding staff. They are all fraught with potential for big errors.
It does pay to review those EOBs, ask questions if something looks wrong to you, and challenge things - like a surgery you didn't have! - when you find mistakes.
BES are you guys using Epic?
This, absolutely! I am on the employer side of healthcare and I am constantly educating employees about reading EOBs, matching bills and EOBS, etc. Mistakes can happen across all aspects of healthcare, so you have to be on the lookout for them. Do not just pay a bill that arrives.
Originally Posted by Lucassb
Our problems with healthcare in this country are complex and do not rest solely on one side. Providers, govt, insurers and even patients all share responsibility for this out of control system.
No kidding. Just had a claim last month the doctor did just that. Yes, same practice, same doctor. Two new patient CPT codes within 4 months. There were two established patient visits for the original dx in between. It didn't matter to me since it was a limited medical benefit plan. They get $50 an over visit up to 5 visits a year no matter what the CPT code. But it caught my attention when auditing the file.
Originally Posted by katarine
And I'm not willing to bet it was intentional.
The good thing about the EMR systems is they do help you track who's New V Est
I work in a hospital lab. I run tests and have nothing to do with billing. I do know that we repeat tests that we aren't paid for and do tests that were misordered or not what the doctor wanted or for some other reason are canceled. Often the RN or Dr doesn't like our results so it's recollected, most times it is the same. Mistakes are made but not on purpose.
I know they are not supposed to bill for a new patient visit just because there is a new diagnosis. But last month I reviewed a file for work where it appears they did just that. New patient visit, 2 established visits for that dx then a new patien visit approx 4.5 months after the first new patient with a totally different type of dx. Yes, I went back and checked. It was the same doctor in the same practice with the same tax identification number for all 4 visits. For my reimbursement purposes due to plan type it didn't matter so I didn't pursue it but it caught my eye.
Originally Posted by relocatedTXjumpr
Trust me working for the insurance company I get plently of blame thrown my way. You know, the evil insurance company that only wants to take your premium and deny all you claims. LOL
The system we have is so very broken there is plenty of blame to go away. I think the brokers are the only ones that make any money in all of this.
But I do have one more claim example from about 6 years ago. Woman was on hospice care and was receiving basic non custom IV nutrition. It would have averaged $19,000 per year. She had to go in-patient and for cost for the same exact IV nutrition for 17 days was $183,000. For just the IV nutrition. The hospital was generous and allowed me to negotiate a 40% instead of 20% discount on the bill. When I looked up the hospital they were moving to all private rooms and were building a three story atrium with fountain and lush tropical plants and were purchasing new top of the line MRI machines. I hope that employer at least paid for a nice tropical plant and maybe a macaw for the atrium.
To be fair, I have seen some of the TV reports on insurance companies where the examiners are instructed to deny first and only investigate and pay if there is an appeal.
There is a hospital local to me that advertises new birthing suites with a pull out couch for dad and a free 44 inch flat screen HD TV. Guess who pays for that? Do I blame the hospital or the insurance company? No. I blame the system.
We as a country, in some areas, are starting to expect that our stay in the hospital is like staying at a nice hotel. We pick the hotel/hospital not by looking at the price only the star rating and somebody else picks up the tab. Of course I am going 5 star how 'bout you? Sweet huh?
Many of the hospitals in my area are building private rooms only wings and converting other wings to private room. No more semi-private.
We as insurance holders and taxpayers are paying for that privacy and the upgraded flat screen tvs, real hardwood floors in the women's treatment wing and the beautiful front lobbies.
When I am in the hospital I don't really care what what the lobby looks like. I want good care and then get me home as fast as possible.
The system is broken in that such a way that it makes it ripe for errors, crooks and scam artists.
We as the consumer have no clue what our insurance will be billed. The insurance company who has made deals to pay a small percentage of the bill so they can brag about savings to prospective clients. The providers of service who have to inflate the bills so they can give those big discounts to the various insurance companies. So in the end you might have 5 patients billed for the same exact office visit and flu shot but they all 5 pay to the doctor a different amount based on who they are insured through or cash pay.
Sorry for medical care, the price should be the price for everybody. As it stands now it is a giant shell game. Plenty of blame to go around.
Okay, I will stop rambling for now.
I am dealing with a payor now who is denying all claims other than an office visit...labs, MRI's, x-rays...they are denying everything for bogus reasons...once I call to dispute "oh, I see the error, we will submit that back for processing"...all they are doing is delaying payment.
I have a group health plan through work...I had a baby in May. My maternity services were covered (I paid my $$$ deductible and co-insurance) but found out two weeks ago after the hospital finally submitted the charges for the newborn care, that my GROUP plan doesnt cover the infant once its born...from the second he is born. So, all of his care is being denied.
Personally, I dont see how this is legal...with my 1st child, he was covered under my group policy for 30 days...at that time I either had to add him to my plan or get his own. This go round, I am being told that United Healthcare doesnt provide coverage for the infant at all, unless you add him to the policy and pay the premium.
Yes, the system is broken, in many ways.
I bill for a provider who boasts as being a "sub specilaist" and who "doesnt want to be paid like a 1st year medical student"...we live in a rural area so our reimbursements are not as high as those say in a larger city. I have to tell him monthly that he can not bill a new PT office visit for a cadiac PT who he saw last month for RA. He doesnt get it.
I think both the insurance industry and the providers are gaming the system.
While I don't think most doctors are billing fraudulently for completely un-provided services, the list of services on the bills I received after my hospital stay for a 3 second walk through during rounds was astonishing. Yes, I am sure the doctor spent more time on me than I actually saw them (checking charts, inputting med orders) but some of these guys had to be getting paid at a rate of $500 for 5 minutes of work. Yes, I know the doctors have to break out for every little thing in order to get paid, but what I saw was ridiculous (and lets not even get into the hospital bill itself- oy).
In my experience, the insurance companies are much worse though. I called and questioned many of the charges and EOBs I was getting (from one of the most reputable insurance companies BTW) from my 2 week hospital stay and half the time was told, that I was indeed correct and they had over-charged me/under-reimbursed the doctor and the other half of the time, some arbitrary rule that was nowhere in any of the paperwork ever made available to me was cited as a reason to cut the reimbursement (i.e., if there are 2 surgeons for a surgery, the payment for the second surgeon is automatically halved regardless of whether the second surgeon was necessary (in my case it was)- uhm, k?).
I ended up paying thousands of dollars in bills for medically necessary surgeries even though I had insurance (don't even get me started on the uninsured- my hospital bill alone was almost $200,000- god help the uninsured).
Our system is so broken it makes me want to weep.
bambam, we see this with Medicare and our imaging dept.
Lets say a patient falls and hurts his arm and leg, Dr says to xray both the right arm and the right leg...if we do both in one day, the reimbursement on the 2nd xray is half of what medicare would normally pay....which is next to nothing already. What some Dr;s are doing is to do the arm xray one day and have the PT come back the next day to xray the leg...it makes a second trip for the PT which is stupid.
I'm pretty sure that's a factor of how your group's policy is written, not how UHC always works. Your ire may be better directed at your employer rather than the insurance company. Better yet, talk to your employer to see if they know that is a provision of their plan and get it changed if they don't know.
Originally Posted by relocatedTXjumpr
Employer didnt know...my HR person had to contact our broker, who contacted someone at UHC. It took weeks, but found out today its a provision under the policy that was sold to our company...and it was not disclosed to either my employer or employees during enrollement. I have looked through the handbook given to us during enrollement and can not find this anywhere in it.
I do not think this is typical of group policies and I question if its even legal, but at the least, it should have been disclosed and it should be in the handbook.
Overstated, as in billed more money for a service than is paid or expected to be paid? 100%. Insurance companies decide how much the provider gets. Providers bill more than they expect to get so they get paid the maximum....
Say you see the doctor. They bill your insurance company $100. Insurance pays $70. Doctor says okay then.
Now say the doctor bills $50. Insurance pays $50, even though they are willing to pay up to $70.
Now, providers billing for services not rendered? There are two scenarios: 1. The way the insurance company describes the service is different from what you think, even though the charge is valid; or 2. Provider is lying to scam the insurance company.
1 happens more than you'd think. I do billing for a doctor's office. Flu shot time, we bill for the actual vaccine AND for the administration of the vaccine (so one code for the stuff that gets injected, and one code for the injection). This usually shows up on EOBs as "flu vaccine" twice, so I have patients accusing me of lying to their insurance company because they didn't get two flu shots. Dude. I know. I didn't bill your insurance company for two flu shots, I promise.
ETA: I had a bad accident a few years ago and broke my leg. When I went in for my 2 week followup, I was fitted for a walking boot. With my insurance, I have to pay 50% of that stuff. I was watching my insurance account online waiting to see how much it was going to be.... Something like a YEAR later, it finally showed up and my insurance paid their half. I got a bill from the people who fitted and sold me the walking boot. I'm like, uh, no. You have 120 days to submit a claim to the insurance, then you're SOL. They billed me a couple times and sent me a letter threatening to send me to collections. I called my insurance, and they hadn't even realized they made a mistake paying for the boot.. they retracted their payment. I sent the boot people a letter and copy of the EOB... basically told them they waited too long to bill my insurance and I do not have to pay, and I would consider further attempts to get the money harassment. I got a voicemail apologizing and promising to leave me alone :D.
The thing is, if they hadn't tried to get money from me, they probably would've been able to keep the money my insurance paid.. oh well. Sucks that they lost a couple hundred bucks, but too bad.
Yes - Drs don't pay attention to their patients and billing doesn't pay attention to what services were actually provided. I have caught many errors - from getting bills for pother people (same last name) to double billing - 2 casts for a broken arm - must have been one on top of the other since he didn't break both arms.