TeamHealth, United, and the impending EM Reimbursement Apocalypse

[sum dude]

So United Health Group has decided they are just going to ignore the CMS RUC physician payment schedule and downcode all Level 5 charts it deems unworthy. Per article, United " Optum Evaluation and Management Professional (E&M Pro) tool will determine the “correct” code-based solely on the patient’s age and the diagnoses submitted on the claim – and if the tool determines that the submitted diagnoses justify a lower-level code, the claim will either be automatically adjusted to the lower-level code or denied “based on the reimbursement structure” in their contract."

This is a huge hit to all EM, given we get 70-80% of our revenue from commercial contracts and UHG is largest insurer in US. In response, Team Health is passing on its hit directly to its doctors, including cutting pay and services like scribes. While I'm sure a lot of us feel schadenfreude for the CMG's, this will eventually pass on to every group. Times are looking bad--this, combined with benchmark fight by insurers, recent headlines of doctors making too much...the war is on doctors, EMTALA ones in particular. Add to this UHG Optum buying up doctor groups, NP's fighting for expansion everywhere...

Everyone here needs to get involved, and MS's, Residents, you guys need to educate yourselves on the current environment of EM. Academics need to stop sitting on their hands and start speaking up for EM everywhere while lobbyists, journalists, and economists rip us up. I fear we've hit the highwater mark of EM--Reimbursement seen 5-10 years ago won't be seen again.

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[TheSingularity]

The **** will trickle down.

If the CMGs are panicking about reimbursement, what you think will happen to the remaining SDGs who have almost zero negotiating power with the insurers?

Then the hospital employed groups will be hit.

All you academics, be prepared for the day when a surviving, newly "lean" CMG takes over your ivory tower. Don't think this can happen? Take a look at the venture capital pillaging of Hahnemann.

Sent from my Pixel 3 using SDN mobile

 

[TooMuchResearch]

UHG is rolling in cash, too. Best way to make money as an insurer? Don't pay for services.

 

[Dr Mantis Toboggan]

I appreciate all such information being shared here. We need to keep each other informed. For the most part this board is not too negative. It’s appropriately concerned.

 

[NurWollen]

I appreciate all such information being shared here. We need to keep each other informed. For the most part this board is not too negative. It’s appropriately concerned.

I don't think there's any other industry that tries so hard to not actually deliver on it's primary product. It's like GM trying really hard to not make cars.

Sent from my SM-G930V using SDN mobile

 

[southerndoc]

FWIW, TeamHealth's contract with UHG may be above market. Regardless, UHG's intentions are clear regarding wanting to drive down reimbursements for all providers.

 

[bravotwozero]

The hospital system our docs work for actually ended up canceling their contract with United Health when they pulled this stunt.


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[GeneralVeers]

I don't think there's any other industry that tries so hard to not actually deliver on it's primary product. It's like GM trying really hard to not make cars.

Sent from my SM-G930V using SDN mobile

Airlines. They basically are credit card companies who *happen* to fly aircraft. Their margins on passenger transport are small, which is why they actively try to make the passenger experience worse. They make huge profit on ancillary fees, and by revenue from co-branded credit cards.

 

[ShockIndex]

This issue is complex and in many ways feeds into the larger problem of surprise billing. Unfortunately, physicians in general, and EM in particular, have done a poor job at messaging and regulating some of our colleagues. This has resulted in articles like this that point to significant up-coding as a reason for patients getting ridiculous bills:

Emergency rooms are monopolies. Patients pay the price.

New data shows how emergency rooms take advantage of their market share, at the expense of their patients.

www.google.com

Insurers then seize on the public sentiment that doctors are cheating and suddenly UHG is a good guy...or even a victim.

So, documenting every chart to level 5 standards is probably not generating good will among patients who show-up for an oil change only to be billed for a engine rebuild. We are out on an island on this one with no friends. If we are not careful, our island may turn into a melting iceberg.

 

[gamerEMdoc]

So, documenting every chart to level 5 standards is probably not generating good will among patients who show-up for an oil change only to be billed for a engine rebuild. We are out on an island on this one with no friends. If we are not careful, our island may turn into a melting iceberg.

Yeah, as bad as it is that a payer will just take it upon themselves to downcode a chart, one thing that can easily get lost is the fact that many EM charts are upcoded unnecessarily. CMGs bill very aggressively. Many 3rd party coders bill very aggressively. You can stretch almost anything out to be a level 4. But the reality is, sometimes some of the stuff that we see is super easy and really shouldn't be billed at a high level. A 21 year old with chest pain isn't a level 5 chart.

It's terrible precedent that a payer can do this, no argument there. But part of the issue is we bring some of this on ourselves by overbilling for a level of care we didn't truly provide. Providers say they did a complete ROS when they didn't ask 14 systems, and some people put that on every chart. They claim they did a comprehensive exam that they didn't do on minor complaints. All to try to bill for higher care than was actually provided to the patient. There are places that legit encourage upcoding charts. That's not cool, its fraudulent. And this is the what its leading too, payers cracking back saying there's no way one ED is seeing 90% level 5 patients and another seeing 25%. They realize there is over-coding. That doesn't make it right that the payer can do that, but our specialty bears some of the blame for why this is happening IMO.

 

[TysonCook]

...I'm also wondering on the dynamics of things that we (the direct care) give. Kaiser comes to mind (as they will do basic w/u and then transfer), but basically at a national level say, "if you are United insured, we will work you up to a level of MSE, but that's it because your insurer does not cover emergency workups". Yes, I realize the nuances of medmal and not working up patients (i.e. the workup is done up front), but we do have some control. It would be nuanced, but basically noting at triage, "if you are UHC covered, you are given a MSE and NOT a full workup".

 

[EctopicFetus]

The degree of misinformation continues to depress me.

The TH thing is because they cant come to a contracted rate with UHG. Note envision was in a similar position and then signed a contract for well over 400% of Medicare. TH is using this as an excuse. Keep in mind the scale that you all believe the CMGs has is a 2 edged sword.

TH and other CMGs felt the pressure of being OON because hospital systems said they wont allow this. instead of being forced in network they said they wont balance bill (they saw the legistlation pending). UHG and others wont let them out of piecemeal agreements whereby they would BB only some places.

The nonsense of SDGs not being able to negaotiate good rates is silliness. If you believe this do explain how a partner in an SDG outearns CMG docs. Hint its not from prepartners. The amount of money being pissed away to cmg admin, recruitment (cause their jobs suck) eats up the relatively minor delta better contracts they have. The old days of CMGs getting 2x SDGs is long gone from their commercial insurers.

Also, documenting to a level 5 chart doesn’t mean it is billed as such. There is likely some upcoding but I would argue outside of CMGs there is way more down coding/under coding.

 

[ShockIndex]

Yeah, as bad as it is that a payer will just take it upon themselves to downcode a chart, one thing that can easily get lost is the fact that many EM charts are upcoded unnecessarily. CMGs bill very aggressively. Many 3rd party coders bill very aggressively. You can stretch almost anything out to be a level 4. But the reality is, sometimes some of the stuff that we see is super easy and really shouldn't be billed at a high level. A 21 year old with chest pain isn't a level 5 chart.

It's terrible precedent that a payer can do this, no argument there. But part of the issue is we bring some of this on ourselves by overbilling for a level of care we didn't truly provide. Providers say they did a complete ROS when they didn't ask 14 systems, and some people put that on every chart. They claim they did a comprehensive exam that they didn't do on minor complaints. All to try to bill for higher care than was actually provided to the patient. There are places that legit encourage upcoding charts. That's not cool, its fraudulent. And this is the what its leading too, payers cracking back saying there's no way one ED is seeing 90% level 5 patients and another seeing 25%. They realize there is over-coding. That doesn't make it right that the payer can do that, but our specialty bears some of the blame for why this is happening IMO.

I think that upcoding is endemic among CMGs and academic EDs, but perhaps for slightly different reasons. The CMGs are mostly fraud - plain and simple. EMCare (now Envision) got their hand slapped multiple times:

The Company Behind Many Surprise Emergency Room Bills (Published 2017)

A study by Yale researchers found that the rate of out-of-network doctor’s bills for customers of a big insurer jumped when EmCare entered a hospital.

www.google.com

EMP (now USACS) was notorious for sending charts back to us requesting additional ROS, exam, or CC billing. I have no reason to think that the situation has improved since I left CMGs 7 years ago.

When it comes to academics, the upcoding is done under the guise of training residents to properly document. However, I’ve personally seen EM upper levels tell off-service interns to always click the “complete ROS performed” box in EPIC on every patient that they see, and to make sure every patient gets a complete physical and ROS - no matter the complaint. Explaining to the upper level that they just committed a felony by conspiring to defraud Medicare returns the usual blank stares. Telling residents to upcode every chart with unnecessary exams and ROS is beyond dumb.

So, no - it doesn’t surprise me that insurers are pushing back on fraud. I’m honestly waiting for the first qui tam suit to fall on a CMG for fraudulently billing CMS. I’d love to be the whistleblower on that one.

 

[gamerEMdoc]

When it comes to academics, the upcoding is done under the guise of training residents to properly document. However, I’ve personally seen EM upper levels tell off-service interns to always click the “complete ROS performed” box in EPIC on every patient that they see, and to make sure every patient gets a complete physical and ROS - no matter the complaint. Explaining to the upper level that they just committed a felony by conspiring to defraud Medicare returns the usual blank stares. Telling residents to upcode every chart with unnecessary exams and ROS is beyond dumb.

I'm not sure that's endemic in academics. I guess it depends on where you are at. I lecture every year to my residents on billing and coding so they understand the ins and outs and properly chart to get compensated for what they did when they get out. But I stress heavily to not abuse caveats like the ROS caveat, and explain that defrauding medicare is in fact a crime and no job is worth going to jail. My hospital in my opinion, actually under-codes for what we do, they are very conservative with the level we bill for, so our #s of 4/5's are way way way below what they were at 7 years ago when we used to use a 3rd party coding group.

 

[gamerEMdoc]

Also, documenting to a level 5 chart doesn’t mean it is billed as such. There is likely some upcoding but I would argue outside of CMGs there is way more down coding/under coding.

Correct. However, saying you reviewed all 14 systems on every patient is fraud, whether that case gets billed at a 5 or not. I get the MDM has to support support the other documentation to bill at the appropriate level. But you can trump up the MDM as well. Some physicians have dot phrases But I've seen dot phrases that automatically spit in stuff claiming that the chest pain they saw was a high risk case of high acuity... blah blah blah... and then use that dot phrase on chest pains in 20 year olds they got an ECG and discharged.

I do agree that in most non-CMG jobs, especially places that don't use a 3rd party coder, undercoding is probably more common than overcoding.

 

[AlmostAnMD]

This would stop quickly if we did just MSE's on anyone with UHC across the country for a few days

"your insurance is UHC? Sorry, all I can do is a screening exam"

I know, I know, lawsuits, etc...but it would solve this quickly

 

[NYEMMED]

This would stop quickly if we did just MSE's on anyone with UHC across the country for a few days

"your insurance is UHC? Sorry, all I can do is a screening exam"

I know, I know, lawsuits, etc...but it would solve this quickly

Or do the whole work up but make patients sign that due to UHC they will need to pay more out of pocket. Patients would be so mad it would be changed in a week

 

[ShockIndex]

Correct. However, saying you reviewed all 14 systems on every patient is fraud, whether that case gets billed at a 5 or not. I get the MDM has to support support the other documentation to bill at the appropriate level. But you can trump up the MDM as well. Some physicians have dot phrases But I've seen dot phrases that automatically spit in stuff claiming that the chest pain they saw was a high risk case of high acuity... blah blah blah... and then use that dot phrase on chest pains in 20 year olds they got an ECG and discharged.

I do agree that in most non-CMG jobs, especially places that don't use a 3rd party coder, undercoding is probably more common than overcoding.

You are correct that the fraud risk is mitigated by conservative coding companies that under-bill. However, there are still some problems:

1) Conspiracy to defraud the US government does not require that a fraudulent chart be billed. All it requires is at least 2 parties agree to do something that would defraud the US. A perfect example would be a boss telling their employees to make sure every patient receives X exam, test, procedure, etc. regardless of complaint or problem so that billing would be maximized. It’s a ridiculously easy standard for the government to meet in order to get an indictment.

2) People who insist on padding every chart to a level 5 are putting their fate in the hands of their coders to save them from themselves. This is a really bad, bad idea.

Bottom line, just document an appropriate history and exam that is appropriate for the complaint. Doing that will keep docs out of court and make them more efficient.

 

[gamerEMdoc]

You are correct that the fraud risk is mitigated by conservative coding companies that under-bill. However, there are still some problems:

1) Conspiracy to defraud the US government does not require that a fraudulent chart be billed. All it requires is at least 2 parties agree to do something that would defraud the US. A perfect example would be a boss telling their employees to make sure every patient receives X exam, test, procedure, etc. regardless of complaint or problem so that billing would be maximized. It’s a ridiculously easy standard for the government to meet in order to get an indictment.

2) People who insist on padding every chart to a level 5 are putting their fate in the hands of their coders to save them from themselves. This is a really bad, bad idea.

Bottom line, just document an appropriate history and exam that is appropriate for the complaint. Doing that will keep docs out of court and make them more efficient.

100% agree.

 

[deleted109597]

Or do the whole work up but make patients sign that due to UHC they will need to pay more out of pocket. Patients would be so mad it would be changed in a week

Hardly. They're already doing that. It's where all the "balance billing" issues are coming from. Pushing it on the patients.
But yes, we could MSE these, and every non-emergency make them go to their PCP. Honestly, it's what's going to happen soon anyway.

 

[TheComebacKid]

I am definitely one of the more negative people who post on this forum, but some of this seems a little prematurely pessimistic.

My understanding is UHC is cutting reimbursements across the board, not just for ED visits. Once the specialists in the outpatient world decide UHC is not worth it and they cut them, patients will be outraged and market forces will push UHC out the door. This move is ultimately incredibly stupid for UHC. While it's true there are a couple of big private insurers, customers who pay for health insurance can take their premiums elsewhere if they find UHC does not have adequate "in network" providers.

All you academics, be prepared for the day when a surviving, newly "lean" CMG takes over your ivory tower. Don't think this can happen? Take a look at the venture capital pillaging of Hahnemann.

I'm really not sure about this. Not saying it can't happen, and clearly CMGs are putting their foot in things like resident education, but CMGs are really going to have a hard time staffing Mass General.

The academic group where I am doing residency actually outbid the contract for an ED against the local SDG and a CMG. When you have residents (cheap) and academicians (cheap), it is possible to run a fairly decent operation and hit metrics for hospitals, especially if your payer mix allows for it. Also academic hospitals are largely subsidized by taxpayer money especially in more underserved areas.

When the motive is profit, a CMG would be foolish to tackle a Cook County or Parkland. When the motive is education, research, service, a non-profit academic group is likely going to run a better operation. Not saying that academic centers don't care about profit, because they clearly do, but they aren't owned by private equity firms and have some different incentives.

Maybe I'm naïve. I agree that things in the academic world are most definitely changing, but it seems to be a different process than what's going on in the community.

 

[Sushirolls]

My understanding is UHC is cutting reimbursements across the board, not just for ED visits. Once the specialists in the outpatient world decide UHC is not worth it and they cut them, patients will be outraged and market forces will push UHC out the door. This move is ultimately incredibly stupid for UHC. While it's true there are a couple of big private insurers, customers who pay for health insurance can take their premiums elsewhere if they find UHC does not have adequate "in network" providers.

As an outpatient PP Psychiatrist, I have observed that UHC patients will either delay for months or year or more getting in with another Psychiatrist until they find one that does accept UHC. They might eventually drive a less desirable distance, or simply wait and limp along with their PCP. I like your thinking, but I'm not too optimistic in this corrective action by outpatient folks dropping UHC. With the trend of most doctors shifting to hospital or health systems groups, its their admin who controls things and they just see *some money.* Those who are surgery/procedural based, or set foot in a hospital for whatever reason, would rather get something for those patients instead of nothing. It just means UHC will be viewed like medicaid conceptually - a private insurance medicaid. The other barrier to correcting UHC race to the bottom is the purchase of UHC by employers. Employers will continue to choose/consider UHC simply because of cost.

 

[TooMuchResearch]

I don't feel bad that most (at least 60%) of physician charts are coded to level 5 at our primary site as our average physician patient (i.e. not fast track PA patient) is 65+ with multiple chronic medical issues and at least one acute issue generally involving the brain, chest, or abdomen. Unless it's a dead leg, then those other parts are usually acutely fine.

You are correct that the fraud risk is mitigated by conservative coding companies that under-bill. However, there are still some problems:

1) Conspiracy to defraud the US government does not require that a fraudulent chart be billed. All it requires is at least 2 parties agree to do something that would defraud the US. A perfect example would be a boss telling their employees to make sure every patient receives X exam, test, procedure, etc. regardless of complaint or problem so that billing would be maximized. It’s a ridiculously easy standard for the government to meet in order to get an indictment.

2) People who insist on padding every chart to a level 5 are putting their fate in the hands of their coders to save them from themselves. This is a really bad, bad idea.

Bottom line, just document an appropriate history and exam that is appropriate for the complaint. Doing that will keep docs out of court and make them more efficient.

 

[TheSingularity]

I do not examine the chest when there is an ankle complaint. Therefore I remove the heart and lung portions from my exam. Sometimes this makes the number of systems examined low. I've gotten emails from CMGs "suggesting" that I document more systems. This is fraud.

 

[gamerEMdoc]

I do not examine the chest when there is an ankle complaint. Therefore I remove the heart and lung portions from my exam. Sometimes this makes the number of systems examined low. I've gotten emails from CMGs "suggesting" that I document more systems. This is fraud.

Correct. One of my past residents messaged me about her hospital (employee, not a cmg) noted her RVUs were low despite her PPH being quite good (she was one of the fastest residents we've had in years). They said it was because she wasn't checking the "all systems reviewed" on every patient and that she needed to do that on every patient she sees to maximize billing. She appropriately told them "nope".

 

[EctopicFetus]

Correct. However, saying you reviewed all 14 systems on every patient is fraud, whether that case gets billed at a 5 or not. I get the MDM has to support support the other documentation to bill at the appropriate level. But you can trump up the MDM as well. Some physicians have dot phrases But I've seen dot phrases that automatically spit in stuff claiming that the chest pain they saw was a high risk case of high acuity... blah blah blah... and then use that dot phrase on chest pains in 20 year olds they got an ECG and discharged.

I do agree that in most non-CMG jobs, especially places that don't use a 3rd party coder, undercoding is probably more common than overcoding.

The ros is tricky and I have seen it done both ways. I have heard people just ask “is there anything else?” Or “any other symptoms” and then say they did a full ros. Others specifically ask bizarre things and rattle them off quickly and then list those in the ros. Both are a waste and unhelpful but the govt set up the game and we are playing it. Is it wrong to say this isn’t happening. Of course some people abuse it. I don’t think that’s ok.
I have asked at the reimbursement conference and in general people think the strategies are within the letter of the law.
None of these things are the intent.

 

[EctopicFetus]

What’s lost in the shuffle is the reality of why we need commercial insurers. It’s to prop up our generally crappy reimbursement from medicaid (often 60-70% of medicare) and self pay which is still around 15% nationally. The lowest I have heard was about 11-12%.
Lost in the pr battle is this reality that we are underpaid by at a minimum 1/4 to 1/3 of our patients.
We have to make this up and that’s how we do it.
Seemingly the battle is lost but the war rages. More losses are coming be it from other insurers or govt legistlation. Hard to remember the last time it looked this bad.

 

[TheSingularity]

Yet as seen in the residency application threads, more sheep coming to the slaughter.

What’s lost in the shuffle is the reality of why we need commercial insurers. It’s to prop up our generally crappy reimbursement from medicaid (often 60-70% of medicare) and self pay which is still around 15% nationally. The lowest I have heard was about 11-12%.
Lost in the pr battle is this reality that we are underpaid by at a minimum 1/4 to 1/3 of our patients.
We have to make this up and that’s how we do it.
Seemingly the battle is lost but the war rages. More losses are coming be it from other insurers or govt legistlation. Hard to remember the last time it looked this bad.

Sent from my Pixel 3 using SDN mobile

 

[BoardingDoc]

The ros is tricky and I have seen it done both ways. I have heard people just ask “is there anything else?” Or “any other symptoms” and then say they did a full ros. Others specifically ask bizarre things and rattle them off quickly and then list those in the ros. Both are a waste and unhelpful but the govt set up the game and we are playing it. Is it wrong to say this isn’t happening. Of course some people abuse it. I don’t think that’s ok.
I have asked at the reimbursement conference and in general people think the strategies are within the letter of the law.
None of these things are the intent.

I am a fan of the full quickfire ROS because you never know when the patient is going to turn out to be more complicated that you thought and now you need to go back and ask all those stupid questions. Moreover, I document a full 10+ system ROS on every patient and I know that I'm not overbilling people as I've seen my breakdown of level 3/4/5 charts and I'm certainly not a level 5 chart factory.

Maybe my coders are just more honest than the CMG coders? I'm not saying that my experience generalizes to everyone else. I AM saying that doing a full (albeit quick) 10 ROS on everyone certainly doesn't constitute fraud.

 

[southerndoc]

I do not examine the chest when there is an ankle complaint. Therefore I remove the heart and lung portions from my exam. Sometimes this makes the number of systems examined low. I've gotten emails from CMGs "suggesting" that I document more systems. This is fraud.

If you check a pulse then it qualifies as the cardiovascular component. I always check pulses in extremity injuries. Likewise, you can visible note if someone is in respiratory distress or using accessory neck muscles. There's the respiratory component.

I listen to heart/lung sounds on every single patient though. People feel like that's what a doctor does. If I see an ankle sprain or finger laceration, they still get a heart/lung exam no matter what the futility in doing it is.

 

[gamerEMdoc]

If you check a pulse then it qualifies as the cardiovascular component. I always check pulses in extremity injuries. Likewise, you can visible note if someone is in respiratory distress or using accessory neck muscles. There's the respiratory component.

I listen to heart/lung sounds on every single patient though. People feel like that's what a doctor does. If I see an ankle sprain or finger laceration, they still get a heart/lung exam no matter what the futility in doing it is.

Right, but you aren't examining 8 body systems when you see an ankle sprain and shouldn't be charting as such. The issue isn't documenting what you actually did even if its a little more than what most people would. The issue is documenting things you definitely did not do. You may examine the skin, neuro, cardiovascular (pulses), and MSK. But I highly doubt you are doing an abdominal exam, eye exam, ENT exam, etc on such basic cases.

 

[BoardingDoc]

Right, but you aren't examining 8 body systems when you see an ankle sprain and shouldn't be charting as such. The issue isn't documenting what you actually did even if its a little more than what most people would. The issue is documenting things you definitely did not do. You may examine the skin, neuro, cardiovascular (pulses), and MSK. But I highly doubt you are doing an abdominal exam, eye exam, ENT exam, etc on such basic cases.

Con: Well appearing, alert in NAD.
Eyes: Lids appear normal
Neck: Supple
Respiratory: No distress
GI: Non-distended
Skin: Dry
Neurologic: No gross weakness
Psych: Normal mood/affect

You can get 8 PE findings on literally any patient without touching them. If your coders are trying to make an ankle sprain a lvl 5 chart then I would consider charting less, otherwise I'd keep playing the stupid checkbox game so that I can insert whatever physical exam findings are actually relevant and focus on the medicine instead of the chart.

 

[Fox800]

Con: Well appearing, alert in NAD.
Eyes: Lids appear normal
Neck: Supple
Respiratory: No distress
GI: Non-distended
Skin: Dry
Neurologic: No gross weakness
Psych: Normal mood/affect

You can get 8 PE findings on literally any patient without touching them. If your coders are trying to make an ankle sprain a lvl 5 chart then I would consider charting less, otherwise I'd keep playing the stupid checkbox game so that I can insert whatever physical exam findings are actually relevant and focus on the medicine instead of the chart.

This. Your basic PE should be a "view from the door" plus checking one of the peripheral pulse and skin temp in one go (takes 2 seconds). Easily hits all of those points. I, like gamerEMdoc, always listen to heart and lungs. Patients "expect it" and it's part of the showmanship of medicine, methinks.

 

[TheSingularity]

I don't listen to heart or lungs unless the complaint merits it. Showmanship be damned. It's a waste of time.

This. Your basic PE should be a "view from the door" plus checking one of the peripheral pulse and skin temp in one go (takes 2 seconds). Easily hits all of those points. I, like gamerEMdoc, always listen to heart and lungs. Patients "expect it" and it's part of the showmanship of medicine, methinks.

Sent from my Pixel 3 using SDN mobile

 

[DoctwoB]

Not an ER doc but that is how I was taught as well. Every patient gets a an accurate (albeit barebones) level 5 history, ROS, and exam. Then what determines the level of the visit is the MDM portion. It is not fraud unless you are documenting things that you did not assess.

 

[thegenius]

This issue is complex and in many ways feeds into the larger problem of surprise billing. Unfortunately, physicians in general, and EM in particular, have done a poor job at messaging and regulating some of our colleagues. This has resulted in articles like this that point to significant up-coding as a reason for patients getting ridiculous bills:

Emergency rooms are monopolies. Patients pay the price.

New data shows how emergency rooms take advantage of their market share, at the expense of their patients.

www.google.com

Insurers then seize on the public sentiment that doctors are cheating and suddenly UHG is a good guy...or even a victim.

So, documenting every chart to level 5 standards is probably not generating good will among patients who show-up for an oil change only to be billed for a engine rebuild. We are out on an island on this one with no friends. If we are not careful, our island may turn into a melting iceberg.

True true....I work with some docs who are very aggressive at indicating someone is very sick via a set of CPT codes when in reality they are not.

 

[ShockIndex]

Not an ER doc but that is how I was taught as well. Every patient gets a an accurate (albeit barebones) level 5 history, ROS, and exam. Then what determines the level of the visit is the MDM portion. It is not fraud unless you are documenting things that you did not assess.

And how would you feel if you took your car in for what you thought would be a $30 oil change only be handed a bill for $500 after the fact, and told that the extra $470 was for a 20-point inspection that every car gets - no matter what.

Before you type anything about MDMs, go back a re-read the articles that I linked from Vox and the NYT that describes how EPs have been doing essentially that across the country. EMCare would immediately increased their level 4&5 billing by 300+% when taking over a contract leaving ESI 4 patients with massive physician bills while facility fees were billed out a much lower acuity.

 

[southerndoc]

Right, but you aren't examining 8 body systems when you see an ankle sprain and shouldn't be charting as such. The issue isn't documenting what you actually did even if its a little more than what most people would. The issue is documenting things you definitely did not do. You may examine the skin, neuro, cardiovascular (pulses), and MSK. But I highly doubt you are doing an abdominal exam, eye exam, ENT exam, etc on such basic cases.

Eye? Any discharge that you noted? Scleral icterus? Can see that from across the room.
ENT? Any stridor, deformed ears, or other visual abnormality you can see/hear from across the room?
Abdomen? Does it look distended to you through their clothes?

You can get a lot just from observation.

 

[DoctwoB]

And how would you feel if you took your car in for what you thought would be a $30 oil change only be handed a bill for $500 after the fact, and told that the extra $470 was for a 20-point inspection that every car gets - no matter what.

Before you type anything about MDMs, go back a re-read the articles that I linked from Vox and the NYT that describes how EPs have been doing essentially that across the country. EMCare would immediately increased their level 4&5 billing by 300+% when taking over a contract leaving ESI 4 patients with massive physician bills while facility fees were billed out a much lower acuity.

But I’m not billing for the Level V Exam and ROS on every patient. I’m billing the appropriate level based on patient complexity and medical decision making which is often a 3 or a 4. The patient only gets billed for the overall visit, not for each component, which means for a new pt visit or consult the lowest of history, exam, and MDM is what determines billing. My point is that IMO MDM should be what determines the level of the visit. So if anything my patient may receive a more comprehensive exam and history then they pay for as I’m doing a level 5 H and P but billing a level 3 because that’s what the MDM supports. But I’d rather do that then have my actual 5s downcoded to 3s because I didn’t put in a family history or only documented 7 organs on exam.

 

[boolin_1]

ok so what does this mean to my MS3 ass

 

[TheSingularity]

It means stay away from EM. Better yet quit medical school.

ok so what does this mean to my MS3 ass

Sent from my Pixel 3 using SDN mobile

 

[boolin_1]

It means stay away from EM. Better yet quit medical school.

Sent from my Pixel 3 using SDN mobile

ok send me your venmo so you can pay my loans

 

[NYEMMED]

ok send me your venmo so you can pay my loans

If things keep going in this direction, good luck ever paying them...

 

[ShockIndex]

But I’m not billing for the Level V Exam and ROS on every patient. I’m billing the appropriate level based on patient complexity and medical decision making which is often a 3 or a 4. The patient only gets billed for the overall visit, not for each component, which means for a new pt visit or consult the lowest of history, exam, and MDM is what determines billing. My point is that IMO MDM should be what determines the level of the visit. So if anything my patient may receive a more comprehensive exam and history then they pay for as I’m doing a level 5 H and P but billing a level 3 because that’s what the MDM supports. But I’d rather do that then have my actual 5s downcoded to 3s because I didn’t put in a family history or only documented 7 organs on exam.

Is it possible that your experience in an office environment is not reflective of what is happening in EDs across America? It may not be reflective of what is happening in your own speciality according to this article:

Why is there a problem with upcoding and overbilling?

The Overbilling Conundrum.

www.medicaleconomics.com

So, you better make darn sure that you are not billing out of proportion to your peers.

Otherwise, here is how it works. A provider uses your logic and documents a level 5 exam and ROS in every patient. CMS audits their charts because they are billing at rates 20% higher than the average in their region. Next thing they know, guys with a gun and a badge show up and seize all of their records - patient, bank, tax...you name it. Then, an Asst. US Attorney has a little talk with them about constructive intent - the fact that all of the charts are written to bill at the highest level is strong evidence that fraud was their intent when billing at rates 20% higher than their peers. They will be told that the government is prepared to seek an felony indictment on 50 or so counts of the most egregious charts where toe pain accidentally slipped through and got billed as a level 5. Each count carries 5 years and $100K if the government goes to trial. Or, the government will accept a misdemeanor guilty plea where they pay $500K or so in fines and lose their ability to bill Medicare for a few years. The vast majority take door # 2.

FWIW, I spent 4 years in the 3 letter agency that shows up to seize the records and returns to slap on the cuffs when (not if) the grand jury returns the true bill for those who choose door #1.

 

[deleted109597]

Before you type anything about MDMs, go back a re-read the articles that I linked from Vox and the NYT that describes how EPs have been doing essentially that across the country. EMCare would immediately increased their level 4&5 billing by 300+% when taking over a contract leaving ESI 4 patients with massive physician bills while facility fees were billed out a much lower acuity.

Not to nitpick but the physician fee is an incredibly low portion of the actual bill.
99214 (level 4) is $90 in Medicare bucks. 99215 is $148. Even for private insurances which are multiples of this, we aren't talking thousand dollar charges.
The facility fee is the majority of the cost. The CMG doesn't get that part, the hospital does.

The reason the CMGs make money on the upcoding is via the aggregate, not the individual bill.

The part that gets me is news like this. UnitedHealth reports nearly $14B in 2019 profit
Why do people always blame the physicians when it's clear the problem isn't with us.

 

[thegenius]

So, no - it doesn’t surprise me that insurers are pushing back on fraud. I’m honestly waiting for the first qui tam suit to fall on a CMG for fraudulently billing CMS. I’d love to be the whistleblower on that one.

No doubt. They are playing the bills. I’m not surprised by this at all. If I were them I would do this too.

The entire problem comes down to the fact that the people who use these services are indirectly paying, or not paying at all, for them. Someone wrote above about going into an $40 oil change and being charged $500 because they did a 20 pt review of systems. The real analogy here is you don't care because your copay is $15. So you get a bill for $15 and might not even see the $500 charge.

 

[ShockIndex]

Not to nitpick but the physician fee is an incredibly low portion of the actual bill.
99214 (level 4) is $90 in Medicare bucks. 99215 is $148. Even for private insurances which are multiples of this, we aren't talking thousand dollar charges.
The facility fee is the majority of the cost. The CMG doesn't get that part, the hospital does.

The reason the CMGs make money on the upcoding is via the aggregate, not the individual bill.

The part that gets me is news like this. UnitedHealth reports nearly $14B in 2019 profit
Why do people always blame the physicians when it's clear the problem isn't with us.

Their operating expenses were more than $220B last year. Their net and operating margins for the past few years seem fluctuate between 4-10% - similar to just about every other well-run insurance company.

Are you equally offended to know that your telecom provider probably brought in similar profit and operates at more than double those margins? Or, is the frustration limited to the businesses that more directly impact your bottom line?

 

[ShockIndex]

No doubt. They are playing the bills. I’m not surprised by this at all. If I were them I would do this too.

The entire problem comes down to the fact that the people who use these services are indirectly paying, or not paying at all, for them. Someone wrote above about going into an $40 oil change and being charged $500 because they did a 20 pt review of systems. The real analogy here is you don't care because your copay is $15. So you get a bill for $15 and might not even see the $500 charge.

That may be true for Medicaid and some Medicare, but it’s certainly not the case for patients with private insurance or on the exchanges with $2000 deductibles and out-of-pocket maximums of $7K.

Don’t get me wrong. I despise Medicaid and nothing pisses me off more than patients and activists who refer to welfare as “insurance.” However, my simple point is that this problem is complex, people on both side of the argument are playing dirty, and we need to be very careful in what we wish for going forward because we are doing stuff that will make our patients hate us.

 

[thegenius]

That may be true for Medicaid and some Medicare, but it’s certainly not the case for patients with private insurance or on the exchanges with $2000 deductibles and out-of-pocket maximums of $7K.

Yup...those private insurance patients don't go to the ER because they will have a $200 copay and pay another $200 as a percentage of the bill. Perhaps that is a good thing, perhaps not!

 

[deleted109597]

Their operating expenses were more than $220B last year. Their net and operating margins for the past few years seem fluctuate between 4-10% - similar to just about every other well-run insurance company.

Are you equally offended to know that your telecom provider probably brought in similar profit and operates at more than double those margins? Or, is the frustration limited to the businesses that more directly impact your bottom line?

I'm not frustrated by capitalism at all.
I am frustrated by people arguing that physicians are the cause of the problems when they ignore that the insurance companies aren't exactly hurting. Especially when they're pushing expenses onto the people who pay the premiums.

It's not like telecom makes you pay for your access and then, should you choose to use your phone, you pay extra. That is, unless you have a terrible plan.
Also, a significant number of people aren't dying from lack of cellphones or high speed internet. The converse is actually true. But hey, cool strawman.