Suspicious Billing Practice?

[TimmyTurner]

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Last week I shadowed at a local pod office of a larger pod group.

This group has multiple offices in a 50 mile radius. The DPM I was shadowing was fairly busy. He had routine nail care appointments stacked all afternoon.

I had shadowed another podiatrist at a stand alone practice once before, and I saw much of the same. One thing I did see this time that I had not seen last time, was the billing.

In once case, a middle aged women in her 50s, non diabetic, received general nail care. The Pod showed me the billing code sheet that he gave to the assistants at the front desk. He explained that he mostly bills patients that received general nail care as having been treated for some type of fungus. Otherwise, the patient would have to pay out of pocket. Patients who pay out of pocket are less likely to return every 3 months.

He was extremely blasé about it. Is this common practice? Taboo? Additionally, what percentage of patients that a practice sees will pay out of pocket for general care? Thank you.

 

[ldsrmdude]

Last week I shadowed at a local pod office of a larger pod group.

This group has multiple offices in a 50 mile radius. The DPM I was shadowing was fairly busy. He had routine nail care appointments stacked all afternoon.

I had shadowed another podiatrist at a stand alone practice once before, and I saw much of the same. One thing I did see this time that I had not seen last time, was the billing.

In once case, a middle aged women in her 50s, non diabetic, received general nail care. The Pod showed me the billing code sheet that he gave to the assistants at the front desk. He explained that he mostly bills patients that received general nail care as having been treated for some type of fungus. Otherwise, the patient would have to pay out of pocket. Patients who pay out of pocket are less likely to return every 3 months.

He was extremely blasé about it. Is this common practice? Taboo? Additionally, what percentage of patients that a practice sees will pay out of pocket for general care? Thank you.

So, I'm certainly no expert (but trying to learn), but it depends on what the actual E/M or procedure code was that was billed, not just the diagnosis. It also depends on the insurance. Did that patient actually have onychomycosis or was that just the diagnosis the doctor put? Did they bill an office visit? Some doctors just worry more about the $$$ and abuse the system by fudging things to get routine care covered that shouldn't be. I'm not saying that is what happened in this case, because I have no idea about the particulars, but there are unfortunately some very shady people out there, and not just with this, but some docs bill all their nail trimmings as nail avulsions, etc. It seems like every week you read about a doctor getting in trouble for shady billing practices.

Here's a PDF that's actually fairly helpful in determining whether a patient would have routine care covered: http://www.podiatry.com/images/eZines/PracticePerfect/185/RoutineFootCareCPTcodes.pdf

 

[TimmyTurner]

Thank you for the PDF. The Pod billed an office visit, and treatment for the 'fungus' even though there was no fungus present. He did mention something about an ingrown sweat gland that he shaved down. The woman had no systemic or chronic condition that I knew of. She had private insurance (Aetna, I beleive).

While the Pod was finishing notes I walked around the front desk and chatted with the office assistants. I asked one of them what happens after they receive the billing sheet from the Pod. She showed me their Apple software, and displayed the screen where the billing took place. The total for that visit came to $230. I was amazed by that. The other Pod I shadowed charged $60 for an office visit, but was in a lower income neighborhood (not economically depressed by any means, but I live near and was shadowing a Pod in a wealthy part of the nation).

My big fear entering Podiatry is the availability of procedures to bill insurance. General nail care is the bread & butter of most practices I visited, but I don't know how these offices sustain if only a fraction of those patients can (rightfully) have their insurance billed. Perhaps I'm wrong, but I'm inclined to believe that few can afford to pay out of pocket for these procedures, and of those who can, an even smaller percentage of that group actually will.

 

[ldsrmdude]

Thank you for the PDF. The Pod billed an office visit, and treatment for the 'fungus' even though there was no fungus present. He did mention something about an ingrown sweat gland that he shaved down. The woman had no systemic or chronic condition that I knew of. She had private insurance (Aetna, I beleive).

Saying a patient has onychomycosis when there is none is shady. I know it's done, but I think it's shady. I should amend some of what I said earlier, it's not always about the money when a doctor tries to get a service covered that shouldn't be. It can also be about increasing patient satisfaction. In the current environment, patient satisfaction matters, a lot. Turns out, that may not always be the best metric:http://www.ucdmc.ucdavis.edu/publish/news/newsroom/6223

While the Pod was finishing notes I walked around the front desk and chatted with the office assistants. I asked one of them what happens after they receive the billing sheet from the Pod. She showed me their Apple software, and displayed the screen where the billing took place. The total for that visit came to $230. I was amazed by that. The other Pod I shadowed charged $60 for an office visit, but was in a lower income neighborhood (not economically depressed by any means, but I live near and was shadowing a Pod in a wealthy part of the nation).

My guess is they billed different levels of service, maybe the patient was a new patient which pays more. Keep in mind that the doctor won't collect what he billed, but some portion of it, so really he could bill anything, but the insurance would only pay a standard fee for that level of service.

My big fear entering Podiatry is the availability of procedures to bill insurance. General nail care is the bread & butter of most practices I visited, but I don't know how these offices sustain if only a fraction of those patients can (rightfully) have their insurance billed. Perhaps I'm wrong, but I'm inclined to believe that few can afford to pay out of pocket for these procedures, and of those who can, an even smaller percentage of that group actually will.

Actually, in my small amount of experience, a fair number of patients will pay for the service out of pocket, depending on what you charge. Most docs that I've talked to charge something like $40-$50 cash for routine care. As far as making enough money, the opportunity is there. If you don't want to make "chip and clip" your bread and butter, then it doesn't have to be. Most podiatrists do some amount of routine care, but there are plenty who don't do much and make a fine living focusing on other aspects of the profession (wound care, sports medicine, etc). Try to find a few other doctors to shadow who do less routine care and focus more on other aspects.

 

[NatCh]

Billing $230 for an initial office visit or consultation, level III, is not at all unreasonable (and as ldsrmdude pointed out, you probably won't get paid that). $60 might have been for an established patient visit, level II maybe. The amount has to do with the level of service with each encounter. Go see any other specialist as a patient then be amazed at what they bill compared to what we bill.

If a patient genuinely does not qualify for nail care then I think it's best to tell them so and inform them that they'll have to pay cash if they want the service. I actually would rather be paid cash and skip the whole insurance step. If a patient does not qualify for nail care but genuinely does have a billable issue, tinea pedis for example, it's legit to bill an office visit if you're actually evaluating and managing that problem. If a patient just wants his nails trimmed but doesn't qualify and doesn't have another billable issue then it's not legit to bill the office visit for return visits.

Some practices are heavily nail care biased and some do very little. I do very little nail care (one patient per day), but I do have a few patients who gladly pay out of pocket for non-covered nail care services. They're not a big part of my practice (less than 1% of my income I'm certain) but I don't actively try to build that aspect of my patient panel. It takes a little time to groom your practice into what you want it to be, so if you don't want to do a lot of nail care then try to develop the aspects that you enjoy.

 

[Creflo]

Can you offer for a patient to pay you cash for a service that is covered by their insurance, if you and the patient agree to leave the insurance company out of it? For example, say a patient has a $5,000 deductible, you offer a cash price of $300 to perform a service that would otherwise cost the patient $500 if insurance was filed, is this possible?

Also, another question, does anyone know if you have to have a business address that is separate from your home address to obtain your medicare provider number? Let's say you are trying to start a part time solo practice and can't afford an office yet.

 

[NatCh]

It's my understanding that if you know the patient has insurance (and you're contracted with that insurance plan) then you must bill their insurance the contracted rate. However, if the patient does not tell you they have insurance then you can bill them your pay out of pocket rate. The patient has to know beforehand to tell you they won't be billing to insurance.

Related: http://selfpaypatient.com/2014/01/03/insured-patients-can-save-money-by-pretending-to-be-uninsured/

I'm not sure about the Medicare enrollment question. Their enrollment website is so incredibly convoluted that's it's usually frustrating trying to find what you're looking for. You may want to call and talk to a live person to find your answer. Good luck.