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  #11  
Old 06-15-2018, 01:48 PM
The_Polymath The_Polymath is offline
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Sounds like fraud to me.
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  #12  
Old 06-15-2018, 03:16 PM
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Yes, sounds clear-cut enough I'd think there's be an opportunity to prosecute for fraud. Is there a good reason why that never (AFAICT) happens?
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  #13  
Old 06-15-2018, 03:19 PM
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Originally Posted by ActurialMike View Post
This happens absolutely all the time. Then insurance companies get blamed for all the high costs.
Insurance companies sell themselves as controlling costs for benefit of consumers. While I don't doubt there's an explanation, as an outsider this seems far below a "minimal" level of cost control. So, I'm ok with them getting some blame here. Even if the answer is "regulatory and privacy rules make it impossible to do much about it" or similar, insurers have enough lobbying power to change the rules if they really want to.
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  #14  
Old 06-15-2018, 03:41 PM
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What can we do about it?

And what does this mean for those providers who refuse to upcode? How can we keep them from being penalized because of the offenders?
I wonder if a simple survey to ask how long the doctor spent with you (the patient) would work? Time isn't the only factor in a level 5 E&M determination but we can estimate the other markers from the diagnosis codes. The survey would just identify the top mismatches to narrow it down.

I tried to do this at <company> without the survey but there was too much to sift through and I ended up creating a lot of work for fraud dept without a very good hit rate.
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  #15  
Old 06-15-2018, 03:42 PM
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Originally Posted by bluecup129 View Post
It does seem like this could be included in call campaigns and/or patient satisfaction surveys- simply asking the patient "how long would you say your appointment lasted?" and comparing to the code.

Although, I don't know that I would even know how long I was at my last PCP visit for.

Also, should the time the patient patient (sic) is sitting alone in an examination room count towards the time? It always seems interminable until the doctor (or whoever) actually shows up. It doesn't seem like it ought to be counted in the coding.
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  #16  
Old 06-15-2018, 03:46 PM
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My patient portal has CPT codes.

Oh, oh, I got a drinking and depression screening (billed charge $40 each) without us even talking about it! (The forms I filled out had checkboxes. Sketchy though.)
Checkboxes actually are probably a screening, but they should have discussed this with you and it's pretty sketchy for them to charge you for two separate screenings like that. They probably only spent 5 or so minutes on that.
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  #17  
Old 06-15-2018, 04:01 PM
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They were just part of the ordinary new patient forms.
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  #18  
Old 06-15-2018, 09:59 PM
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Checkboxes actually are probably a screening, but they should have discussed this with you and it's pretty sketchy for them to charge you for two separate screenings like that. They probably only spent 5 or so minutes on that.
You should see the complexities with the ACA preventive requirement. Ask a question to the doc about any issue or condition and it gets flagged differently and cost sharing kicks in. Lots of folks were getting surprise bills after the fact.
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  #19  
Old 06-18-2018, 09:04 AM
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And what does this mean for those providers who refuse to upcode? How can we keep them from being penalized because of the offenders?
They risk getting cut out of the network.
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  #20  
Old 06-18-2018, 11:00 AM
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I did a lot of studies at my last employer with these codes. I concluded that providers will rape the insurance companies till they (the Ins Co) do something about it. Some of our contracts called for something like a 3% increase a year. Well, providers want 8% raises so they upcode.

My PCP and I went to high school together. He doesn't admit to knowing the codes nor what gets billed. He, and a nurse, will be in the room with me and they are both typing away on laptops.

It takes a medical coder to look at these charts and put in #'s. So there is a gap in what happened and who codes I believe. I wanted to apply to be a coder for like 3 months just to see what really goes on in Medical Records departments. Maybe I will again. It pays like $18 an hour though, so I better save some $.

Bottom line, there is a lot insurance contractors can and should do with respect to these claims. But that's their job, not mine. And when I questioned their contracting efforts I got the big IGNOR button. Oh well.

Also, PCP's and docs do a review outside of your appointment. But still, not 50 minutes worth to make your 10 minute visit, 60 minute bill appropriate.

My PCP is the largest $ maker in WI. How do I know that? Well, I have friends in the right places and I am not afraid to ask questions. My PCP sees 72-75 patients a day. I am starting to think how he can manage that many patients. There is only 24 hours in a day, and if he's billing 30 minute visits for all these people consistently then there is a HYOOOGE probability of fraud.

I have been trying to get some work at the hospitals locally. I am starting to think that they won't hirew me because I will see what really goes on.
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