"Disease management"

[Dog_luver]

So i went to an "endocrinologist" a while back, and they charged me for both the office visit, and they charged me for "disease management" over $200 bucks, with a cose of S0315. The offices which are now all closed across the state claim that they are *two* separate things to have an office visit AND a disease evaluation. I say WTH? I am filling a fraud charge w/my insurance and making a complain w/the state medical board. How can they try to charge for the same thing twice? The billing people claim that they are two separate things, not the same. When I ask so what do you get during an office visit then? They can't tell me. When I've asked what does disease management entail they also can't tell me. I have NEVER heard of this before.

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[group_theory]

Disease management should already be part of the medical complexity decision tree when billing E/M 99213-99215 (or 99203-99205 if new)

It appears, based on your description, the practice is trying to double-dip on the medical decision making by unbundling or fragmenting the care (ie billing for History, billing for ROS, billing for PE, billing for A/P). It can't be done with Medicare/Medicaid, or private insurance - but if you are private pay (without insurance), then they can do this. Most often, with insurance (whether commercial, private, or Medicare/Medicaid/Tricare), the office/practice have already agreed to a set reimbursement schedule/rate and you are only responsible for the copays and whatever is "optional" that insurance doesn't pay (the practice is obligated to let you know in advance before you agree to the optional service). I''m pretty sure "disease management" is bundled into the office visit.

If you report this practice to the right "organization", you may be entitled (if convinced or plea agreement) to a percentage of the fine under the Federal False Claims Act (also known as the Whistle Blower act). You will need a lawyer (who, if you have a strong case, will gladly take it on contingent) to file a Qui Tam lawsuit on your behalf.

 

[Dog_luver]

Disease management should already be part of the medical complexity decision tree when billing E/M 99213-99215 (or 99203-99205 if new)

It appears, based on your description, the practice is trying to double-dip on the medical decision making by unbundling or fragmenting the care (ie billing for History, billing for ROS, billing for PE, billing for A/P). It can't be done with Medicare/Medicaid, or private insurance - but if you are private pay (without insurance), then they can do this. Most often, with insurance (whether commercial, private, or Medicare/Medicaid/Tricare), the office/practice have already agreed to a set reimbursement schedule/rate and you are only responsible for the copays and whatever is "optional" that insurance doesn't pay (the practice is obligated to let you know in advance before you agree to the optional service). I''m pretty sure "disease management" is bundled into the office visit.

If you report this practice to the right "organization", you may be entitled (if convinced or plea agreement) to a percentage of the fine under the Federal False Claims Act (also known as the Whistle Blower act). You will need a lawyer (who, if you have a strong case, will gladly take it on contingent) to file a Qui Tam lawsuit on your behalf.

That is EXACTLY what I have said! Because I said I am fine with getting charged $249 for a new patient visit, but then when I ask - so if disease evaluation/management is not included, then what does the patient visit get me? Obviously it HAS to include EVALUATION of a medical complaint. The one billing person tells me well for walking into the clinic you get charged a new patient visit. WTH! I told them this is double dipping - I just had one new patient visit, and you are double billing me. They keep insisting that they are not - that seeing the DOCTOR and being EVALUATED are TWO different things. Sorry for the caps. It's incomprehensible in my mind. I even tell them, I'm a doctor and this is not how billing works - you are billing me twice for the same thing. When I kept asking them what does the office visit get me they are unable to tell me. When I ask them what the "disease management " gets me they are unable to tell me. And to make matters worse, since I was skeptical of the knowledge base of this "doctor" I never got the labs done and never went back again. So there is no diagnosis or disease to manage. Further when I went to a good doctor and got a ton of labs done they were all normal so not sure what they would be managing. It's been incredibly frustrating. This corporation has also closed all their clinics across the state which is not surprising. I have bluecross blue shield, and like I told them I think they saw a patient with good insurance and salivated. They also did not tell me of this - if they would have said, the "evaluation" is separate, I would have turned around and left and made an appt. with a real doctor. I have NEVER heard of a legit physician billing for the office visit AND their evaluation. If you are not being evaluated in an office visit then why go to see the doctor? Further the insurance has already paid for the actual visit itself. To make matters worse, they have sent this to collections! So I have to write collections before they report it to my credit to let them know I'm disputing this claim. I also am filling a complaint with the medical board.

 

[Raryn]

That is EXACTLY what I have said! Because I said I am fine with getting charged $249 for a new patient visit, but then when I ask - so if disease evaluation/management is not included, then what does the patient visit get me? Obviously it HAS to include EVALUATION of a medical complaint. The one billing person tells me well for walking into the clinic you get charged a new patient visit. WTH! I told them this is double dipping - I just had one new patient visit, and you are double billing me. They keep insisting that they are not - that seeing the DOCTOR and being EVALUATED are TWO different things. Sorry for the caps. It's incomprehensible in my mind. I even tell them, I'm a doctor and this is not how billing works - you are billing me twice for the same thing. When I kept asking them what does the office visit get me they are unable to tell me. When I ask them what the "disease management " gets me they are unable to tell me. And to make matters worse, since I was skeptical of the knowledge base of this "doctor" I never got the labs done and never went back again. So there is no diagnosis or disease to manage. Further when I went to a good doctor and got a ton of labs done they were all normal so not sure what they would be managing. It's been incredibly frustrating. This corporation has also closed all their clinics across the state which is not surprising. I have bluecross blue shield, and like I told them I think they saw a patient with good insurance and salivated. They also did not tell me of this - if they would have said, the "evaluation" is separate, I would have turned around and left and made an appt. with a real doctor. I have NEVER heard of a legit physician billing for the office visit AND their evaluation. If you are not being evaluated in an office visit then why go to see the doctor? Further the insurance has already paid for the actual visit itself. To make matters worse, they have sent this to collections! So I have to write collections before they report it to my credit to let them know I'm disputing this claim. I also am filling a complaint with the medical board.

So file a complaint with your insurance company. It will be sorted out. Not too much else we can do about it.

 

[Dog_luver]

So file a complaint with your insurance company. It will be sorted out. Not too much else we can do about it.

I'm not asking the forum to do anything about it. I was simply asking if this is common practice as I've never heard about this and sounds illegal. Since you are an endocrinologist, do you charge for both an office visit and disease management separately?

 

[Raryn]

I'm not asking the forum to do anything about it. I was simply asking if this is common practice as I've never heard about this and sounds illegal. Since you are an endocrinologist, do you charge for both an office visit and disease management separately?

No. When we bill a clinic visit, it is billed just for the visit (9920X or 9921X). The only additional charges would be if a procedure was done (in office ultrasound, biopsy), smoking cessation counseling was given (a modest additional charge can often be captured), and with some insurance companies if an insulin pump was adjusted or a continuous glucose monitor reviewed.

What your guy did is not illegal unless you have Medicare, but it may be against his contract with your insurance company. Hence why they'd be the best ones to sort it out.

Googling code "S0315" brings up an initial visit to a disease management program. If there is a formal program that you enrolled in (met with a diabetes educator for example), it might even be completely legit. It's not one that I'm personally familiar with though.

 

[NotAProgDirector]

Although I've never heard of this, it doesn't look "illegal" per se.

S0315 is a billing code for: "Disease management program; initial assessment and initiation of the program"

This set of codes (all in the S0311-5 range) are all used to document care that is happening out of an office visit. So, for example, if you have a patient who is obese and then you enroll them in a weight loss program and have your nurse / nutritionist contact them by phone every few days, these are the codes you use. The S0315 is the initial code for enrollment, and then you can bill S0311 for each month in the program. A practice might use this if you had telehealth equipment given to you, for example. I have no idea if this applies to your problem at all.

S0315 is a new code, only created in 2016. It is not billable to Medicare -- it's considered bundled as part of the other E&M codes. Most likely, this was created in the hopes that these types of things might be billable to Medicare in the future -- i.e. you could manage a diabetic over the phone, and get paid a monthly fee for doing that. It's also apparently a temporary code, so no one knows if it will be removed in the future.

As mentioned, if you don't have Medicare, and especially if you don't have insurance at all, they probably have assigned a fee to the code. The fee gets reduced to zero as soon as they bill your insurance company. If you have no insurance, the fee is likely to stay. Chances are, if you bring this to their attention, they will drop the fee to 0.

So why do this at all? I'm not certain. The code does not have any RVU's associated with it. It's probably only billable to people with no insurance, which seems pointless. But perhaps they are setting up processes in the hope that they will be able to bill in the future. Or, they want to track some aspect of their business and use this non-billable code to do so.

 

[Dog_luver]

Although I've never heard of this, it doesn't look "illegal" per se.

S0315 is a billing code for: "Disease management program; initial assessment and initiation of the program"

This set of codes (all in the S0311-5 range) are all used to document care that is happening out of an office visit. So, for example, if you have a patient who is obese and then you enroll them in a weight loss program and have your nurse / nutritionist contact them by phone every few days, these are the codes you use. The S0315 is the initial code for enrollment, and then you can bill S0311 for each month in the program. A practice might use this if you had telehealth equipment given to you, for example. I have no idea if this applies to your problem at all.

S0315 is a new code, only created in 2016. It is not billable to Medicare -- it's considered bundled as part of the other E&M codes. Most likely, this was created in the hopes that these types of things might be billable to Medicare in the future -- i.e. you could manage a diabetic over the phone, and get paid a monthly fee for doing that. It's also apparently a temporary code, so no one knows if it will be removed in the future.

As mentioned, if you don't have Medicare, and especially if you don't have insurance at all, they probably have assigned a fee to the code. The fee gets reduced to zero as soon as they bill your insurance company. If you have no insurance, the fee is likely to stay. Chances are, if you bring this to their attention, they will drop the fee to 0.

So why do this at all? I'm not certain. The code does not have any RVU's associated with it. It's probably only billable to people with no insurance, which seems pointless. But perhaps they are setting up processes in the hope that they will be able to bill in the future. Or, they want to track some aspect of their business and use this non-billable code to do so.

Umm no. I have private insurance (blue cross blue shield) and they not only never informed me of this but they are billing $217 in ADDITION to the regular office visit. No counseling, diagnosis, medications, nurse visit, telehealth or anything else was done. I'm sure it HAS RVUs as they are asking $217 and wanting to send me to collections for it even though the insurance has already paid for the actual visit (per the legally agreed upon charges allowed by the insurance). No one can tell me what was "done" for this "disease management" even though they keep telling me they are "legitimate charges" an that it's "separate from seeing the doctor." They have not dropped it to 0, and have sent me threatening collections letters.

 

[NotAProgDirector]

The situation is very, very strange. Assuming you don't fit into the categories I detailed above, seems crazy to me.

As mentioned, you have several options:

1. You could contact the physician who saw you. They actually filled out the billing data. They probably can remove the charge, if appropriate.
2. You could contact your insurer. Something seems wrong here. I am surprised BCBS is letting this charge through. Googling "BCBS S0315" finds this link: https://www11.anthem.com/provider/nv/f5/s1/t5/pw_e230964.pdf?refer=ahpprovider&state=n All plans are different, but they are clear this is bundled and not billable. Even if you have a high deductible plan, they should zero out this charge.
3. Given that you deny any services associated with this code, you could report them -- either to the hospital (if hospital based), or the state insurance oversight. Or, you could talk to a lawyer about a whistleblower suit -- co-billing an S code with an E&M code is kosher, but only if they actually deliver said services. Else it's fraud, and if this is widespread the payout could be huge.

 

[Dog_luver]

The situation is very, very strange. Assuming you don't fit into the categories I detailed above, seems crazy to me.

As mentioned, you have several options:

1. You could contact the physician who saw you. They actually filled out the billing data. They probably can remove the charge, if appropriate.
2. You could contact your insurer. Something seems wrong here. I am surprised BCBS is letting this charge through. Googling "BCBS S0315" finds this link: https://www11.anthem.com/provider/nv/f5/s1/t5/pw_e230964.pdf?refer=ahpprovider&state=n All plans are different, but they are clear this is bundled and not billable. Even if you have a high deductible plan, they should zero out this charge.
3. Given that you deny any services associated with this code, you could report them -- either to the hospital (if hospital based), or the state insurance oversight. Or, you could talk to a lawyer about a whistleblower suit -- co-billing an S code with an E&M code is kosher, but only if they actually deliver said services. Else it's fraud, and if this is widespread the payout could be huge.

I know!! I have been dealing with this for about a year, as I was busy w/residency stuff and I kept getting the run around. Now that I have a bit more time I've been trying to deal with it but it is insane. The billing department when I call tell me that I have to talk to the doctor's office because they just process codes given by the doctor and they can't tell me anything else. When i called the doctor's office they tell me that I have to talk to billing. This is a company that had a ton of offices across my state, but all of the offices have closed! All of the medical records have been moved to a different city, so I am hunting those down. Like I said this was simply a clinic visit to see an endocrinologist, the entire appt took about 15 minute, this person told me we'll do labs and if they are normal you don't have to see me again. I felt the "doctor" was terrible and incompetent so I never did any of the labs and never went back. I have never been allowed to talk to the doctor. BCBS told me I can file a fraud charge. No services other than the clinic visit occurred, unless some additional "services" were fabricated that were added to my visit after I left. I even told the doctor that I was a resident so I find this even more mind numbing! I think I am going to go the Whistleblower suit - I have given them the option to take care of this but they won't do anything at this time. Although weirdly enough initially they removed the charges and then they reinstated them! I am thinking that given the sudden closure of all their clinics across the state, something fishy might be going on. Might be a mixed blessing.

 

[hamstergang]

I would just caution you to separate out the codes billed from how good you felt the service was. Talking about how bad this doctor was as a doctor is irrelevant to whether or not they met the minimum standards for the codes billed. It makes you sound more angry than correct while you might have a legitimate concern.

 

[Dog_luver]

I would just caution you to separate out the codes billed from how good you felt the service was. Talking about how bad this doctor was as a doctor is irrelevant to whether or not they met the minimum standards for the codes billed. It makes you sound more angry than correct while you might have a legitimate concern.

Fair enough, although the quality of the exam is indeed important if they are saying they are doing things they are not. For example, listening to the chest over a sweater, or palpating pulses over jeans, etc. and reporting a complete PE. It just simply adds to the fraudulent type of practice that they were. I don't find it suprising that all their clinics closed.

 

[rokshana]

Umm no. I have private insurance (blue cross blue shield) and they not only never informed me of this but they are billing $217 in ADDITION to the regular office visit. No counseling, diagnosis, medications, nurse visit, telehealth or anything else was done. I'm sure it HAS RVUs as they are asking $217 and wanting to send me to collections for it even though the insurance has already paid for the actual visit (per the legally agreed upon charges allowed by the insurance). No one can tell me what was "done" for this "disease management" even though they keep telling me they are "legitimate charges" an that it's "separate from seeing the doctor." They have not dropped it to 0, and have sent me threatening collections letters.

so the only person you saw on that visit? no diabetes educator? no dietician? no self management program? as pointed out, that is the only thing i can think of that would fit in that...but i've never used that code (or heard of it until now).

 

[Dog_luver]

so the only person you saw on that visit? no diabetes educator? no dietician? no self management program? as pointed out, that is the only thing i can think of that would fit in that...but i've never used that code (or heard of it until now).

The ONLY person I saw during that visit was the so called doctor, and no I do not have DM, I had a concern for thyroid issues, and ultimately do not have thyroid issues either (went to different doctor later), but no DM educator, dietician, self management program or anything else you've mentioned. The only thing this person told me was we'll do labs, and if labs negative you don't need to see me again. Nothing else. The ridiculous billing company tells me that the "evaluation" of the "disease" is billed separately from the office visit. What a bunch of garbage! I contacted a legal firm already though. This smells fishy. And reading online about the closure of all their clinics in my state, it specifically states that they had issues with "insurance billings" and financial issues. This might end up being a gold mine for me. We shall see.

 

[Dog_luver]

The situation is very, very strange. Assuming you don't fit into the categories I detailed above, seems crazy to me.

As mentioned, you have several options:

1. You could contact the physician who saw you. They actually filled out the billing data. They probably can remove the charge, if appropriate.
2. You could contact your insurer. Something seems wrong here. I am surprised BCBS is letting this charge through. Googling "BCBS S0315" finds this link: https://www11.anthem.com/provider/nv/f5/s1/t5/pw_e230964.pdf?refer=ahpprovider&state=n All plans are different, but they are clear this is bundled and not billable. Even if you have a high deductible plan, they should zero out this charge.
3. Given that you deny any services associated with this code, you could report them -- either to the hospital (if hospital based), or the state insurance oversight. Or, you could talk to a lawyer about a whistleblower suit -- co-billing an S code with an E&M code is kosher, but only if they actually deliver said services. Else it's fraud, and if this is widespread the payout could be huge.

So I have been going around and around with this issue. I talked to my insurance company they told me indeed that it is not a billable service but that the doctor's office can bill for whatever they want even if not medically necessary. I feel incredibly frustrated with this. I can't find anyone who has ever billed for this code, nor under what circumstances this can be billed.

 

[NotAProgDirector]

This might end up being a gold mine for me. We shall see.

If all the clinics are closed, I doubt you're going to find Au in that mine. I expect it will be Pb. Can't get blood from a stone. Can't get cash from a bankrupt practice.

You're stuck in an infinite loop. You can't dispute the charge because the offices are closed. The charge has rolled to a collection agency, so they just want their money and have no interest in helping you. if the practice is closed / bankrupt, there's nothing you can do. The unpaid bill will sit on your credit report and cause havoc. I have no idea what you can do. I doubt a contingency lawyer will take this, with no one to sue. Paying a lawyer to fix it is an option, but honestly it's probably cheaper and easier to just pay the bill. Although it will injure your soul to do so. Luckily, you have medical insurance to cover that.

 

[norwood]

The unpaid bill will sit on your credit report and cause havoc. I have no idea what you can do.

Pull your credit report -- if you sort through all the scams, you're entitled to one REAL and TRULY FREE report from each of the big three, once per year (without having to sign up for anything at all, an instant sign that you're not on the right site).

You can challenge erroneous negatives. Do it. You don't have to pay or sign up for things to do that, either. If any of the big three try to make you think otherwise, call FTC, which regulates them.

Been there, after a shady business sold a nonexistent 'debt' to a very low-end collection agency. End result was that FTC kicked Equifax around, Equifax apologized to me, and the negative was gone forever.

 

[Dog_luver]

If all the clinics are closed, I doubt you're going to find Au in that mine. I expect it will be Pb. Can't get blood from a stone. Can't get cash from a bankrupt practice.

You're stuck in an infinite loop. You can't dispute the charge because the offices are closed. The charge has rolled to a collection agency, so they just want their money and have no interest in helping you. if the practice is closed / bankrupt, there's nothing you can do. The unpaid bill will sit on your credit report and cause havoc. I have no idea what you can do. I doubt a contingency lawyer will take this, with no one to sue. Paying a lawyer to fix it is an option, but honestly it's probably cheaper and easier to just pay the bill. Although it will injure your soul to do so. Luckily, you have medical insurance to cover that.

No I would rather write the board and file other charges such as fraud charges that will stick with the doctor forever and damage their license permanently even if there is no money. It's become personal. My soul is priceless, I can't pay something that is fraud. At least my soul is happy that they are closed. Oh well.

 

[norwood]

No I would rather write the board and file other charges such as fraud charges that will stick with the doctor forever and damage their license permanently even if there is no money. It's become personal. My soul is priceless, I can't pay something that is fraud. At least my soul is happy that they are closed. Oh well.

In the end, being bitter only hurts you. Contact the credit bureaus and get the false negative taken off your credit report. Then you keep your $200, and your sanity.

 

[bannie22]

I was scammed too by an orthopedic doctor.

Be wary of physicians. All of them just trying to make a quick buck.

 

[bannie22]

No I would rather write the board and file other charges such as fraud charges that will stick with the doctor forever and damage their license permanently even if there is no money. It's become personal. My soul is priceless, I can't pay something that is fraud. At least my soul is happy that they are closed. Oh well.

I respect that. Principles much more important than $200.

 

[VA Hopeful Dr]

No I would rather write the board and file other charges such as fraud charges that will stick with the doctor forever and damage their license permanently even if there is no money. It's become personal. My soul is priceless, I can't pay something that is fraud. At least my soul is happy that they are closed. Oh well.

Depending on the state, there's a very good chance that nothing like that will happen.

Improper insurance billing will not get you a board reprimand in my state. Full stop.

 

[Raryn]

I was scammed too by an orthopedic doctor.

Be wary of physicians. All of them just trying to make a quick buck.

This probably isn't the best forum to express that sentiment.

 

[VA Hopeful Dr]

This probably isn't the best forum to express that sentiment.

I'm 90% sure that's a troll

 

[Dog_luver]

When it is done purposefully, I'm sure it can. Reason why all these news of doctors going to jail. And let's keep in mind that these clinics closed across the state due to "insurance billing issues" and "financial issues" - not to mention that my state is one of the most adversarial state board in the nation, so not exactly a friendly one. I'm happy to give this person a strike on their license.

Depending on the state, there's a very good chance that nothing like that will happen.

Improper insurance billing will not get you a board reprimand in my state. Full stop.

 

[Dog_luver]

It's very interesting an after a long and round-about discussion with the insurance company yesterday, it wasn't until one of APD's comments clicked until this morning - the insurance agreed that it was a bundled/non-reimbursable charge yet the charge has a fee attached to it - so the original fee was $217 and the allowable charge like 70$. So something is amiss still. I have found this whole thing very annoying but interesting as well. Again I don't expect anyone in the forum to do anything about it, I just was posting something that I thought was wild and crazy!

I respect that. Principles much more important than $200.

 

[Dog_luver]

It's not about being "bitter" it's about doing what's right. Are we advocating for insurance fraud now? If this is done to someone who is another physician can you imagine what's being done to clueless patients? This place left hundreds of people without care - they did not even send letters to notify anyone of anything, they just put a note on their door. Clearly there is a large scam here. I am an individual of principle. Even if there is 0 money in this, I have to do what's right. Just as if I saw a colleague who was intoxicated, or unethical, etc. I wouldn't just be like oh well they are my colleague and friend, i'll let it slide. Nope.

In the end, being bitter only hurts you. Contact the credit bureaus and get the false negative taken off your credit report. Then you keep your $200, and your sanity.

 

[VA Hopeful Dr]

When it is done purposefully, I'm sure it can. Reason why all these news of doctors going to jail. And let's keep in mind that these clinics closed across the state due to "insurance billing issues" and "financial issues" - not to mention that my state is one of the most adversarial state board in the nation, so not exactly a friendly one. I'm happy to give this person a strike on their license.

That's only if they defraud the government. Improperly billing Aetna isn't a crime.

You can look up board actions (they are public knowledge). Go see if anyone else in your state has gotten dinged for this. Its certainly possible, but not something I hear about very often.

 

[Dog_luver]

That's only if they defraud the government. Improperly billing Aetna isn't a crime.

Insurance fraud is indeed a crime.

You can look up board actions (they are public knowledge). Go see if anyone else in your state has gotten dinged for this. Its certainly possible, but not something I hear about very often.

 

[VA Hopeful Dr]

Depends on whether you did so knowingly. If that doctor actually thought that billing both was OK, its not fraud. That's why I made the distinction of "improperly billing".

 

[gutonc]

I'm 90110% sure that's a troll

Fixed that for you.

 

[WheezyBaby]

If all the clinics are closed, I doubt you're going to find Au in that mine. I expect it will be Pb.

Offer the clinic a deal. Plato o plomo

 

[Dog_luver]

The situation is very, very strange. Assuming you don't fit into the categories I detailed above, seems crazy to me.

As mentioned, you have several options:

1. You could contact the physician who saw you. They actually filled out the billing data. They probably can remove the charge, if appropriate.
2. You could contact your insurer. Something seems wrong here. I am surprised BCBS is letting this charge through. Googling "BCBS S0315" finds this link: https://www11.anthem.com/provider/nv/f5/s1/t5/pw_e230964.pdf?refer=ahpprovider&state=n All plans are different, but they are clear this is bundled and not billable. Even if you have a high deductible plan, they should zero out this charge.
3. Given that you deny any services associated with this code, you could report them -- either to the hospital (if hospital based), or the state insurance oversight. Or, you could talk to a lawyer about a whistleblower suit -- co-billing an S code with an E&M code is kosher, but only if they actually deliver said services. Else it's fraud, and if this is widespread the payout could be huge.

Hey aPD, where did you find that? I have looked and have found other sources for my insurance saying the same thing but my own insurance is unaware of which codes are being used and what's reimbursable so I'm trying to look at my specific state. I'm wondering where you specifically found that? Thanks!!

 

[NotAProgDirector]

All I did was google "bcbs 0315", and it was the second hit.