TeamHealth, United, and the impending EM Reimbursement Apocalypse

[sum dude]

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?

You do realize 14 B (it was actually 19 B in EBITDA in 2019) is the 19th most profitable company in the world, more than Microsoft, Disney, or Toyota). UHG pulls in more profit than Blackstone (TH owner) or KKR (Envision) make. Poor $750 B insurance companies. The big reason doctors are in the situation they are in is b/c they are naive about how business and politics work. Health Insurers commit billions in fraud a year, and people here are quoting insurer-funded studies blaming doctors.

Truth of the matter is that average ED collection per bill is about $150 or so, which is less than it costs to get a plumber to your house. EMTALA is an unfunded mandate that shift costs to commercial payors, who have decided they don't want to pay any more. Yes their profit margins are relatively modest at 5%, but their revenue has increased 10% per year (United has 245B in revenue), which equals what they've raised in premiums and deductibles every year. Add to this fact they now own PBM's, which lets them skirt the MLR. Optum also bought Davita, making it the largest employer of physicians in the country.

Truth is pay is coming down, and politicians and insurers are scrambling to find cheaper care. That means NP's will be "just as good as doctors" and capitation will be the norm. It's up to doctors to defend what they do, and in EM, every patient gets subsequently more complex every year due to co-morbidities, aging population, and lack of decent primary care follow-up. EM has one of hardest job out there--we need to take ownership over what we do, stop letting suits buy the groups which maximize profit by cutting staffing and squeezing every drop out of the charts, and come up with new, innovative ways to provide better healthcare to patients when they get discharged. It's up to us to educate ourselves on business management and govt. policy, and come up with solutions. Stop listening to the media, politicians, and talking economists who couldn't even run a McDonalds who are trying to tell us how to manage patients.

Otherwise, we're toast.

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[Brigade4Radiant]

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.

well I mean how many level 2-3 charts are their did you supervise themed students laceration? Often times it’s the upper level resident.

Also you can’t have it both ways you can’t say physicians commit fraud everyday and then force physicians to sign charts of NP and PAs that they have never seen and accept full liability.

 

[TooMuchResearch]

In residency we plainly documented that the MS3/4 did the wound repair. Before we started supervising students they very directly told us to document accurately even if it meant no reimbursement.
#notacmgresidency

well I mean how many level 2-3 charts are their did you supervise themed students laceration? Often times it’s the upper level resident.

Also you can’t have it both ways you can’t say physicians commit fraud everyday and then force physicians to sign charts of NP and PAs that they have never seen and accept full liability.

 

[DoctwoB]

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.

You’re right an office is not the ER, though i spend plenty of time billing ER or inpatient consults as well. And I appreciate your insight on the enforcement end. But how is performing and documenting a level 5 exam in every patient fraud if the billing is for the appropriate level? Say for that ankle pain Patient. I document a level 5 H&P and then bill a level 3 based on the MDM. I get how over billing for a minor complaint is fraudulent, but how is “overdocumenting” for correct billing A problem!

 

[Brigade4Radiant]

In residency we plainly documented that the MS3/4 did the wound repair. Before we started supervising students they very directly told us to document accurately even if it meant no reimbursement.
#notacmgresidency

But they were still billed as if you did it fully though that’s the point there was no discount for the med student doing it since you supervised

 

[ShockIndex]

You do realize 14 B (it was actually 19 B in EBITDA in 2019) is the 19th most profitable company in the world, more than Microsoft, Disney, or Toyota). UHG pulls in more profit than Blackstone (TH owner) or KKR (Envision) make. Poor $750 B insurance companies. The big reason doctors are in the situation they are in is b/c they are naive about how business and politics work. Health Insurers commit billions in fraud a year, and people here are quoting insurer-funded studies blaming doctors.

Truth of the matter is that average ED collection per bill is about $150 or so, which is less than it costs to get a plumber to your house. EMTALA is an unfunded mandate that shift costs to commercial payors, who have decided they don't want to pay any more. Yes their profit margins are relatively modest at 5%, but their revenue has increased 10% per year (United has 245B in revenue), which equals what they've raised in premiums and deductibles every year. Add to this fact they now own PBM's, which lets them skirt the MLR. Optum also bought Davita, making it the largest employer of physicians in the country.

Truth is pay is coming down, and politicians and insurers are scrambling to find cheaper care. That means NP's will be "just as good as doctors" and capitation will be the norm. It's up to doctors to defend what they do, and in EM, every patient gets subsequently more complex every year due to co-morbidities, aging population, and lack of decent primary care follow-up. EM has one of hardest job out there--we need to take ownership over what we do, stop letting suits buy the groups which maximize profit by cutting staffing and squeezing every drop out of the charts, and come up with new, innovative ways to provide better healthcare to patients when they get discharged. It's up to us to educate ourselves on business management and govt. policy, and come up with solutions. Stop listening to the media, politicians, and talking economists who couldn't even run a McDonalds who are trying to tell us how to manage patients.

Otherwise, we're toast.

I think you are toast if EM’s collective response is going to be some version of corporate class warfare. One special interest group of high earners railing against another because they are too profitable doesn’t play well with most of the country. Keep in mind that this issue of upcoding of ED charts that I’m referring to often doesn’t even pass through the insurance companies since the charges are often below deductible and OOP maximums. It is the patient-physician interface that is being eroded by this behavior. There are ways this can be fixed so that everyone is reasonably compensated, but defending the status quo is not one of them.

As for EMTALA, yes it is a pain in the ass. It’s also one that everyone practicing since 1986 knew about when they submitted their rank list. It’s not going anywhere, so consider changing your practice environment if doing MSEs on toe pain is about to make your head explode.

well I mean how many level 2-3 charts are their did you supervise themed students laceration? Often times it’s the upper level resident.

Also you can’t have it both ways you can’t say physicians commit fraud everyday and then force physicians to sign charts of NP and PAs that they have never seen and accept full liability.

I never billed for a student procedure that I didn’t personally supervise and provide direct participation.

I’m simply here warning physicians to stop pissing off their patients by upcoding their charts - I’m not involved in making physicians sign anything. Better yet, nobody has ever made me sign a mid level chart that I’ve never seen, so I have no idea what you are describing.

 

[gamerEMdoc]

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.

Yeah but in the grand scheme of things, for a company, magnified over millions of patients, that's a lot of money. If you upcode a 3 to a 5 that doubles the payment. So yeah, for the patient bill its not a ton, but magnified over a huge number of patients, there is a reason CPGs encourage upcoding. It definitely leads to much bigger profits.

At our institution alone, we had an institutional review several years ago of our coding from our hospital admin a while back that felt that our 3rd party ED coders were coding more aggressive than they should. So they let them go and hired internal coders to be more discretionary about the coding. It led to a loss in over a million dollars in billed care in one year. But they felt like it was too big of a liability, so they just ate the loss. That's one hospital.

 

[gamerEMdoc]

Interestingly, 2021 is bringing a change to CMS codes. Level 2-4 will all pay the same and I don't believe there will be any documentation standards for the lower code (2-4) group beyond the standard for a level 2 chart (which is almost no documentation). So it will require almost no documentation to reach the non-level 5 standard. That will pay about about $90 I think. If you bill for a level 5, you will have to document up to that, although there are some alternatives to get there based on time I think. Alternatively, you'll be able to bill for time spent instead of your complexity of documentation. So if you have a basic case but its a complete time sink, like a CYS case, you'll be able to bill for the time you spend on the case.

 

[ShockIndex]

You’re right an office is not the ER, though i spend plenty of time billing ER or inpatient consults as well. And I appreciate your insight on the enforcement end. But how is performing and documenting a level 5 exam in every patient fraud if the billing is for the appropriate level? Say for that ankle pain Patient. I document a level 5 H&P and then bill a level 3 based on the MDM. I get how over billing for a minor complaint is fraudulent, but how is “overdocumenting” for correct billing A problem!

There are 2 elements that the government will consider in deciding to go after a provider criminally vs. assigning a civil penalty. 1) were charts incorrectly billed at higher services than what was needed or rendered, and 2) was there criminal intent to commit fraud. Having all of your charts documented to a level 5 goes a long way to establishing the second arm. Constructive intent means that someone gathered all the parts necessary for a crime to occur - be it fraud or building a bomb. In this case, the prosecutor will say, “So you designed all your charts so that any billing error would always be benefit you at the expense of the government...how convenient.”

It sounds like you code your own charts which means it’s unlikely that you will run afoul unless you get really sloppy. However, this is not the case for most EPs who submit their charts to 3rd party coders who establish the level of complexity. This is why our industry has a huge problem with this that is compounded by the fact that many CMGs employ their own coding outfits that are financially incentivized to fudge. Moreover, EPs need to stop with the plausible deniability excuse when it comes to CMG upcoding and surprise out of network billing in their name.

 

[thegenius]

I would love the day when a chart for a routine finger lac reads like (meaning THE ENTIRE CHART)

32F cut her 3rd left middle phalanx while cutting steak. About 2 cm long, flex/ex tendon exam normal. Anesthesized with 1% lido, irrigated with water and sutured with 2 interrupted 4.0 nylon. Tetanus is UTD.

Ahh that day will come soon. Maybe I'll run my cash-only pseudo-ER one day. It will lose money. It will go under. But it will be a glorious time when I'm there.

 

[TooMuchResearch]

They told us they couldn't bill for procedures done by students and that this is the price of educating. Unless they were lying, they didn't bill for the procedures.

But they were still billed as if you did it fully though that’s the point there was no discount for the med student doing it since you supervised

 

[deleted109597]

Yeah but in the grand scheme of things, for a company, magnified over millions of patients, that's a lot of money. If you upcode a 3 to a 5 that doubles the payment. So yeah, for the patient bill its not a ton, but magnified over a huge number of patients, there is a reason CPGs encourage upcoding. It definitely leads to much bigger profits.

I mean, apart from me saying exactly that, my statement was in response to yet another ludicrous fallacy where an analogy was made for someone getting billed 3-4x the rate of an oil change. The whole point was that individual charts don't change much, but the aggregate does.

And yes, 2-4 is going to be combined to reduce this silliness. But I don't see this as the government throwing a bone. That's bait and we all should know it.
If suddenly we go from ~20% Level 5s to 50+%, the audit guns will be leveled and you know it.


Also, for the record, the government will punish you almost as hard for chronically undercoded as it does for overcoding.

 

[deleted941485]

I mean, apart from me saying exactly that, my statement was in response to yet another ludicrous fallacy where an analogy was made for someone getting billed 3-4x the rate of an oil change. The whole point was that individual charts don't change much, but the aggregate does.

And yes, 2-4 is going to be combined to reduce this silliness. But I don't see this as the government throwing a bone. That's bait and we all should know it.
If suddenly we go from ~20% Level 5s to 50+%, the audit guns will be leveled and you know it.


Also, for the record, the government will punish you almost as hard for chronically undercoded as it does for overcoding.

Ofcourse CMS made it sound like this simplification would help you. Nothing is free in this world. You want less documentation? Fine, you’ll pay for it in the form of lower reimbursement upfront and the audit police on the back end when level 5 visits suddenly skyrocket.

 

[thegenius]

So do we know what those new EM level 2-4 charts are going to be worth, in RVUs?

 

[ShockIndex]

I mean, apart from me saying exactly that, my statement was in response to yet another ludicrous fallacy where an analogy was made for someone getting billed 3-4x the rate of an oil change. The whole point was that individual charts don't change much, but the aggregate does.

And yes, 2-4 is going to be combined to reduce this silliness. But I don't see this as the government throwing a bone. That's bait and we all should know it.
If suddenly we go from ~20% Level 5s to 50+%, the audit guns will be leveled and you know it.


Also, for the record, the government will punish you almost as hard for chronically undercoded as it does for overcoding.

I don’t know why you would call it a ridiculous analogy since it was the EXACT analogy that was given in a Senate committee just last month by patients who were affected by it - people billed massively out of network fees for simple care that was ridiculously upcoded to level 4 and 5 visits. It is also getting a ton of national media attention because it feeds into the surprise billing problem.

Patients with high deductibles, those on exchanges, and the working uninsured go to the ED for what would normally be a level 2 or 3 visit - uncomplicated back pain, lacerations, wrist fracture, low risk chest pain, etc. They have no way of knowing what the estimated cost of their care will be, and they think that the hospital is in their network.

A month later, they get a $2+K bill. While the facility fees often dwarf the physician fees, there are plenty of examples of MD fees being more expensive because the physician group was out of network. Moreover, our colleagues are driving these fees with ridiculous practices like giving patients “loading doses” of IV antibiotics for uncomplicated infections, IV pain meds for patients who can otherwise take PO, IV fluids for mild dehydration, labs for BS chest pain, etc.

Keep in mind these patients are not protected by government health plan price controls. Making matters worse, there are plenty of examples where the physician fee is upcoded to a level 4 or 5 visit while the in-network facility fee reflects a much lower acuity.

For us to deny this is happening and significant means that there is a certain degree of tone deafness as to what is being done in our name. We either regulate ourselves or prepare to be regulated by others.

 

[KGflyboy]

So do we know what those new EM level 2-4 charts are going to be worth, in RVUs?

This is what I'm waiting to see. Less charting nonsense for billing purposes sounds great, but if it is accompanied by decreased reimbursement I'm no longer happy about this.

 

[TooMuchResearch]

The only one I'll disagree with is the BS chest pain as I've had more than a few BS chest pain that have had serious pathology. The others I agree with, and I do my best to avoid IV interventions when there is high probability oral interventions will be sufficient.

I don’t know why you would call it a ridiculous analogy since it was the EXACT analogy that was given in a Senate committee just last month by patients who were affected by it - people billed massively out of network fees for simple care that was ridiculously upcoded to level 4 and 5 visits. It is also getting a ton of national media attention because it feeds into the surprise billing problem.

Patients with high deductibles, those on exchanges, and the working uninsured go to the ED for what would normally be a level 2 or 3 visit - uncomplicated back pain, lacerations, wrist fracture, low risk chest pain, etc. They have no way of knowing what the estimated cost of their care will be, and they think that the hospital is in their network.

A month later, they get a $2+K bill. While the facility fees often dwarf the physician fees, there are plenty of examples of MD fees being more expensive because the physician group was out of network. Moreover, our colleagues are driving these fees with ridiculous practices like giving patients “loading doses” of IV antibiotics for uncomplicated infections, IV pain meds for patients who can otherwise take PO, IV fluids for mild dehydration, labs for BS chest pain, etc.

Keep in mind these patients are not protected by government health plan price controls. Making matters worse, there are plenty of examples where the physician fee is upcoded to a level 4 or 5 visit while the in-network facility fee reflects a much lower acuity.

For us to deny this is happening and significant means that there is a certain degree of tone deafness as to what is being done in our name. We either regulate ourselves or prepare to be regulated by others.

 

[ShockIndex]

The only one I'll disagree with is the BS chest pain as I've had more than a few BS chest pain that have had serious pathology. The others I agree with, and I do my best to avoid IV interventions when there is high probability oral interventions will be sufficient.

We should be able to dispo the vast majority of 0 and 1 HEART score patients with nothing more than an ECG and CXR. These are “no risk” patients for ACS and can usually be PERC’ed out for VTE.

Meanwhile, EP groups across the country put a provider in triage where all manner of ridiculousness is ordered all in the name of facilitating disposition and massaging LWOT metrics. So, extensive serologic studies and even imaging are ordered on low-risk chest pain, young people with UTIs, flank pain, headaches, minor head injury, etc. All of this then gets documented in the physician note and drives-up complexity. The mere concept of “physician in triage” where shotgun tests are ordered with minimal history and no exam should be abhorrent to EPs.

 

[gamerEMdoc]

Im not sure how the 2-4 coding merger will effect things. Seems the RVU will be basically be between a 3 and below a 4. Not having to chart much should make efficiency easier, and easier cases will now pay out more, at the cost of 4’s paying a little lower. We’ll see what effect it has in the longrun. I can tell you, from an rvu standpoint, Id be jumping at every fast track patient I could if an ankle sprain was going to be equal to a non-high risk abd pain essentially.

Apparently there will also be separate modifiers to increase the rvus within the 2-4 group.

Idk all the details. Time will tell.

 

[deleted941485]

Im not sure how the 2-4 coding merger will effect things. Seems the RVU will be basically be between a 3 and below a 4. Not having to chart much should make efficiency easier, and easier cases will now pay out more, at the cost of 4’s paying a little lower. We’ll see what effect it has in the longrun. I can tell you, from an rvu standpoint, Id be jumping at every fast track patient I could if an ankle sprain was going to be equal to a non-high risk abd pain essentially.

Apparently there will also be separate modifiers to increase the rvus within the 2-4 group.

Idk all the details. Time will tell.

Rest assured the fast track will remain the purview of NPs and PAs for the foreseeable future. You’ll have to shiv their supervising physician (assuming that’s still the case) in order to partake.

 

[gamerEMdoc]

Rest assured the fast track will remain the purview of NPs and PAs for the foreseeable future. You’ll have to shiv their supervising physician (assuming that’s still the case) in order to partake.

*During the hours of 8-6p.

 

[BoardingDoc]

..

We should be able to dispo the vast majority of 0 and 1 HEART score patients with nothing more than an ECG and CXR. These are “no risk” patients for ACS and can usually be PERC’ed out for VTE.

Yeah we should. If you don't live in a state with great tort reform though, the risk reward is completely not there.

 

[deleted109597]

I don’t know why you would call it a ridiculous analogy since it was the EXACT analogy that was given in a Senate committee just last month by patients who were affected by it - people billed massively out of network fees for simple care that was ridiculously upcoded to level 4 and 5 visits. It is also getting a ton of national media attention because it feeds into the surprise billing problem.

Just because it was used at a Senate committee doesn't mean it isn't ridiculous. No less than Obama himself used the trope of "why would you give good diabetes care when you can make $50k on an amputation". Also, surprise billing is literally when the insurance company doesn't cover what they're supposed to. So, the words you used are literally an indictment on the media perspective of this, or of your own interpretation.

Patients with high deductibles, those on exchanges, and the working uninsured go to the ED for what would normally be a level 2 or 3 visit - uncomplicated back pain, lacerations, wrist fracture, low risk chest pain, etc. They have no way of knowing what the estimated cost of their care will be, and they think that the hospital is in their network.

Not knowing their estimated cost of care is a hospital and EMTALA issue. You simply cannot tell them up front, as it might discourage them from seeking care. Comically, the party that people love to rag on the most, FSEDs, does a really good job of this (as long as they're not hospital affiliated).

A month later, they get a $2+K bill. While the facility fees often dwarf the physician fees, there are plenty of examples of MD fees being more expensive because the physician group was out of network. Moreover, our colleagues are driving these fees with ridiculous practices like giving patients “loading doses” of IV antibiotics for uncomplicated infections, IV pain meds for patients who can otherwise take PO, IV fluids for mild dehydration, labs for BS chest pain, etc.

IV meds (or IM) is not and never will be part of the professional fee. If docs are doing this, they're not lining their own pockets, they're lining the pockets of the hospital. Also, "often" for dwarf? I'm pretty sure, based on this conversation, that you have no idea how much the professional fee vs the facility fee for an EM visit actually is.

Keep in mind these patients are not protected by government health plan price controls. Making matters worse, there are plenty of examples where the physician fee is upcoded to a level 4 or 5 visit while the in-network facility fee reflects a much lower acuity.

I agree. The professional fee is still less than 10% of the total bill. Thus, the extra $50 is a drop in the bucket.

For us to deny this is happening and significant means that there is a certain degree of tone deafness as to what is being done in our name. We either regulate ourselves or prepare to be regulated by others.

No, what you're doing is basically blaming the docs while holding hospitals and insurance companies blameless.

 

[thegenius]

..
Yeah we should. If you don't live in a state with great tort reform though, the risk reward is completely not there.

I agree. I agree with a lot of what ShockIndex says. He is often spot on. We are not at the point of not doing trops though. We need evidence to back that up, and that will be very hard to pass the IRB.

 

[ShockIndex]

IV meds (or IM) is not and never will be part of the professional fee. If docs are doing this, they're not lining their own pockets, they're lining the pockets of the hospital. Also, "often" for dwarf? I'm pretty sure, based on this conversation, that you have no idea how much the professional fee vs the facility fee for an EM visit actually is.

I thought I was clear that I was referring to physicians driving up facility charges with IV meds. For example, I ask residents not to give toradol to back pain because it drives up the facility fees when Motrin will do just fine. However need for IV meds, specifically parenteral controlled substances, is part of the risk component scoring of the MDM that coders use to justify higher levels of complexity in the professional fee. This is a big one since we love to give IV narcotics...at least until recently. Giving drugs like insulin or IV electrolytes does as well because it requires monitoring. I’ve been told conflicting things about IVF from different coding companies - some say that fluids documented as a bolus drive up the risk score to “high” because it’s resuscitation that requires monitoring to prevent adverse reactions. Other companies disagree and leave all fluids except those with additives as low risk.

As for surprise billing, I think you are oversimplifying things. I’d agree that it’s largely an insurance company issue, but our speciality has dirt on its face with a significant number of physician group who seem to intentionally avoid contracts with the hospital’s insurers.

Also, I’m not holding hospitals and insurance companies blameless. I’m simply pointing out places where EPs need to improve. Being unwilling to critically examine one‘s own behavior is key to survival.

 

[ShockIndex]

I agree. I agree with a lot of what ShockIndex says. He is often spot on. We are not at the point of not doing trops though. We need evidence to back that up, and that will be very hard to pass the IRB.

Abstract number 9 at SAEM last May: Error - Cookies Turned Off

I presented the abstract. The manuscript will be submitted in a couple of weeks but the major results are the same. The overall MACE rate in HEAR (everything except troponin) 0 and 1 was 2/448. Using the HEART Pathway the MACE rate of HEAR 0 was 0/82. For HEAR 1, the MACE rate was 2/366 and the 2 patients had Type 2 MIs in the setting of recent cocaine use.

Of note, there were 7 patients with HEAR scores of 1 with troponin elevations that were not due to ACS. They were people with non-ACS acute or chronic myocardial injury. For example, one patient had Takasubo cardiomyopathy, another had pericarditis, and yet another had mesothelioma eating their heart. A couple were even adjudicated as lab errors in young, healthy people with single blip troponin elevations that quickly became undetectable and went on to have normal imaging. That gave us a net reclassification index of only 0.3%.

In other words, HEART Score 0 are the 18 year olds with chest pain from doing push-up. A troponin in them is more likely to lead you down an non-therapeutic path. HEAR 1 is a little more defensible but unlikely to provide a meaningful change in management outside of cocaine use (and those simply got ASA, benzos, and watched for 12 hours).

 

[deleted109597]

I thought I was clear that I was referring to physicians driving up facility charges with IV meds. For example, I ask residents not to give toradol to back pain because it drives up the facility fees when Motrin will do just fine. However need for IV meds, specifically parenteral controlled substances, is part of the risk component scoring of the MDM that coders use to justify higher levels of complexity in the professional fee. This is a big one since we love to give IV narcotics...at least until recently. Giving drugs like insulin or IV electrolytes does as well because it requires monitoring. I’ve been told conflicting things about IVF from different coding companies - some say that fluids documented as a bolus drive up the risk score to “high” because it’s resuscitation that requires monitoring to prevent adverse reactions. Other companies disagree and leave all fluids except those with additives as low risk.

View attachment 293261

As for surprise billing, I think you are oversimplifying things. I’d agree that it’s largely an insurance company issue, but our speciality has dirt on its face with a significant number of physician group who seem to intentionally avoid contracts with the hospital’s insurers.

Also, I’m not holding hospitals and insurance companies blameless. I’m simply pointing out places where EPs need to improve. Being unwilling to critically examine one‘s own behavior is key to survival.

I am not aware of any rank and file EP that gets to dictate whether or not a group gets to accept or deny a contracted rate with an insurer.
OTOH, I have sat in meetings with insurance companies where they have told us that they will give us 80% of Medicare or no deal. That's not a winnable argument. You cannot fall on the sword for that. The TH/United schism is similar. They're not going to offer us anything, and we are required by law to see it anyway. This is not winnable at all.

I once worked for EmCare/Envision. They would often sent emails saying what we needed to document to get paid to rehydrate a dehydrated patient. They never said to push IV/IM meds to increase billing. I only learned this after I owned my own freestanding.

 

[ShockIndex]

I am not aware of any rank and file EP that gets to dictate whether or not a group gets to accept or deny a contracted rate with an insurer.
OTOH, I have sat in meetings with insurance companies where they have told us that they will give us 80% of Medicare or no deal. That's not a winnable argument. You cannot fall on the sword for that. The TH/United schism is similar. They're not going to offer us anything, and we are required by law to see it anyway. This is not winnable at all.

I once worked for EmCare/Envision. They would often sent emails saying what we needed to document to get paid to rehydrate a dehydrated patient. They never said to push IV/IM meds to increase billing. I only learned this after I owned my own freestanding.

I suspect that the out-of-network issue is going to get solved on the local level. Meaning, hospitals will threaten the contracts and privileges of any group or physician that will not contract with the hospital’s insurance partners. Such is the public and political outcry and CEOs are hearing it from patients, politicians, and media. I think that I’m already starting to see this happening in anesthesia where surprise billing is also too common. For example, Atrium Health in Charlotte gave the boot to its anesthesia group last year. A lot of issues were at play, but I recall out of network billing being a big one. St. Joseph’s in Ann Arbor just canned their anesthesia providers and is suing them for breech of contract because their contract required the group network with the hospital’s insurance.

The more I think about it, this is could a significant threat to CMGs and may start a trend toward more hospital employee group models. Nobody cares if CMGs go belly-up, but local hospitals being effected 10 or 20 years from now will be more noticeable to policy makers when the physicians and hospitals are more closely aligned in a hospital employee model.

 

[thegenius]

We should be able to dispo the vast majority of 0 and 1 HEART score patients with nothing more than an ECG and CXR. These are “no risk” patients for ACS and can usually be PERC’ed out for VTE.

Meanwhile, EP groups across the country put a provider in triage where all manner of ridiculousness is ordered all in the name of facilitating disposition and massaging LWOT metrics. So, extensive serologic studies and even imaging are ordered on low-risk chest pain, young people with UTIs, flank pain, headaches, minor head injury, etc. All of this then gets documented in the physician note and drives-up complexity. The mere concept of “physician in triage” where shotgun tests are ordered with minimal history and no exam should be abhorrent to EPs.

Well you technically need a trop for the HEART score, but I understand your sentiment. Until there is good tort reform though, patients and doctors a like are risk-adverse about missing ischemic chest pain.

 

[bravotwozero]

I suspect that the out-of-network issue is going to get solved on the local level. Meaning, hospitals will threaten the contracts and privileges of any group or physician that will not contract with the hospital’s insurance partners. Such is the public and political outcry and CEOs are hearing it from patients, politicians, and media. I think that I’m already starting to see this happening in anesthesia where surprise billing is also too common. For example, Atrium Health in Charlotte gave the boot to its anesthesia group last year. A lot of issues were at play, but I recall out of network billing being a big one. St. Joseph’s in Ann Arbor just canned their anesthesia providers and is suing them for breech of contract because their contract required the group network with the hospital’s insurance.

The more I think about it, this is could a significant threat to CMGs and may start a trend toward more hospital employee group models. Nobody cares if CMGs go belly-up, but local hospitals being effected 10 or 20 years from now will be more noticeable to policy makers when the physicians and hospitals are more closely aligned in a hospital employee model.

This is already happening in Houston to some extent. Two of the four major hospital systems here dumped their CMGs and transitioned to the W-2 hospital employee model. One of the two remaining is HCA, which is joined at the hip to envision nationally so might not happen there. The fourth is us. Our group just inked a new contract with the hospital, who has told us they do not have any interest right now in making us their employees. For now.

Our hospital also forced our group to be in network for all insurance carriers that they’re in network for, despite the fact that we never balance billed any of our OON patients, which prompted the merger of our smaller, local CMG with a national one.


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[pkwraith]

I do agree that the amount of overuse of IV antibiotics (even Po antibiotic in the ED vs a prescription), over use of IV Hydration, and unnecessary labs. In fact, I would argue that most EM Physicians would understand that, many have reviewed the literature. The problem is that the patient don't and in many ways are insulated from the costs by insurance. They are the ones that are demanding IV medications (because it works better) or labs (just to check things out) or CT (look for cancer) and if a physician pushes back or tries to educate, it takes one patient complaint (and it will be more than one patient complaint) and that physician's practice will likely start changing.

For the oil analogy, in the ED, it is like someone going in to get a routine oil change, demanding the highest grade oil (despite their car not needing it), new tires and transmission changed. And when costs are brought up. "I have good insurance.". When that is prevalent enough, everyone gets swept along with it, including the unfortunate people that are only there for just an oil change.

 

[ShockIndex]

I do agree that the amount of overuse of IV antibiotics (even Po antibiotic in the ED vs a prescription), over use of IV Hydration, and unnecessary labs. In fact, I would argue that most EM Physicians would understand that, many have reviewed the literature. The problem is that the patient don't and in many ways are insulated from the costs by insurance. They are the ones that are demanding IV medications (because it works better) or labs (just to check things out) or CT (look for cancer) and if a physician pushes back or tries to educate, it takes one patient complaint (and it will be more than one patient complaint) and that physician's practice will likely start changing.

For the oil analogy, in the ED, it is like someone going in to get a routine oil change, demanding the highest grade oil (despite their car not needing it), new tires and transmission changed. And when costs are brought up. "I have good insurance.". When that is prevalent enough, everyone gets swept along with it, including the unfortunate people that are only there for just an oil change.

Where I see this still happening the most is with Medicaid recipients. There is also some of this going on with surrogate decision makers of Medicare patients who want “everything” done because they have no skin in the game. Having a Medicaid patients tell me the tests that they want because they have “good insurance” was among my last straws before leaving EM.

 

[ShockIndex]

Well you technically need a trop for the HEART score, but I understand your sentiment. Until there is good tort reform though, patients and doctors a like are risk-adverse about missing ischemic chest pain.

See the linked abstract in post 76.

However, keep in mind that there is a significant difference in the HEART Scores and the HEART Pathway that Simon Mahler developed. However, I dare say that a significant number of EPs already forego troponin testing in young, health patients who have a normal ECG and a weak story. Our paper simply quantifies their “no risk” status for people who do not have enough experience to use gestalt.

 

[Dr Mantis Toboggan]

It is good insurance. For them.

Where I see this still happening the most is with Medicaid recipients. There is also some of this going on with surrogate decision makers of Medicare patients who want “everything” done because they have no skin in the game. Having a Medicaid patients tell me the tests that they want because they have “good insurance” was among my last straws before leaving EM.

 

[TheSingularity]

Yeah that's when I say "nope we're not doing that" and walk out of the room

Where I see this still happening the most is with Medicaid recipients. There is also some of this going on with surrogate decision makers of Medicare patients who want “everything” done because they have no skin in the game. Having a Medicaid patients tell me the tests that they want because they have “good insurance” was among my last straws before leaving EM.

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[ShockIndex]

It is good insurance. For them.

But is it? Look at the Oregan study:

https://www.nejm.org/doi/full/10.1056/NEJMsa1212321

Expanding Medicaid coverage increases healthcare utilization with minimal to no return on actual improved healthcare outcomes. Sure, it makes people subjectively feel less depressed and provides marginal compensation to hospitals for indigent care, but is the juice worth the squeeze in terms of improving health? Better yet, how will we feel in a decade with a permanent underclass of lifelong Medicaid recipients who might have otherwise eventually achieved non-government insurance (Medicaid was once a largely transitional program).

In my mind, it’s pretty strong evidence that what ails America is not inadequate healthcare access, but poor personal decision making that leads to both poor health and poverty. The decision to sell drugs or be an obese smoker results in an early demise regardless of how much money the government throws at the problem.

Personally, I’d favor scrapping Medicaid for all but highly select populations (children, certain cancers, ALS, T21, paraplegics, etc) and using that money to directly compensate hospitals for indigent acute care services. It doesn’t seem that the vast dollars spent are a cost effective endeavor at improving actual health.

 

[ShockIndex]

Yeah that's when I say "nope we're not doing that" and walk out of the room

Sent from my Pixel 3 using SDN mobile

Not only are Medicaid patients rampant consumers of resources, they complain to Patient and Family Relations as well as CMS at vastly higher rates than patients with other payer sources. They make military dependents look docile (EMTALA does not apply to military hospitals and I had no reservations telling the dependents to bugger off when they came in looking for oxy and Xanax).

 

[Dr Mantis Toboggan]

Oh I just meant as far as the ED goes. My assumption was they could come to the ED as often as they want, without a copay.

But maybe I’m wrong about that.

But is it? Look at the Oregan study:

https://www.nejm.org/doi/full/10.1056/NEJMsa1212321

Expanding Medicaid coverage increases healthcare utilization with minimal to no return on actual improved healthcare outcomes. Sure, it makes people subjectively feel less depressed and provides marginal compensation to hospitals for indigent care, but is the juice worth the squeeze in terms of improving health? Better yet, how will we feel in a decade with a permanent underclass of lifelong Medicaid recipients who might have otherwise eventually achieved non-government insurance (Medicaid was once a largely transitional program).

In my mind, it’s pretty strong evidence that what ails America is not inadequate healthcare access, but poor personal decision making that leads to both poor health and poverty. The decision to sell drugs or be an obese smoker results in an early demise regardless of how much money the government throws at the problem.

Personally, I’d favor scrapping Medicaid for all but highly select populations (children, certain cancers, ALS, T21, paraplegics, etc) and using that money to directly compensate hospitals for indigent acute care services. It doesn’t seem that the vast dollars spent are a cost effective endeavor at improving actual health.

 

[EctopicFetus]

Interestingly, 2021 is bringing a change to CMS codes. Level 2-4 will all pay the same and I don't believe there will be any documentation standards for the lower code (2-4) group beyond the standard for a level 2 chart (which is almost no documentation). So it will require almost no documentation to reach the non-level 5 standard. That will pay about about $90 I think. If you bill for a level 5, you will have to document up to that, although there are some alternatives to get there based on time I think. Alternatively, you'll be able to bill for time spent instead of your complexity of documentation. So if you have a basic case but its a complete time sink, like a CYS case, you'll be able to bill for the time you spend on the case.

Unless I am missing something this is for outpt only and not for ED e/m codes. The issue as you nailed is this will lower overall pay for These codes.

 

[TheSingularity]

Not only are Medicaid patients rampant consumers of resources, they complain to Patient and Family Relations as well as CMS at vastly higher rates than patients with other payer sources. They make military dependents look docile (EMTALA does not apply to military hospitals and I had no reservations telling the dependents to bugger off when they came in looking for oxy and Xanax).

Let them complain. IDC.

 

[gamerEMdoc]

Unless I am missing something this is for outpt only and not for ED e/m codes. The issue as you nailed is this will lower overall pay for These codes.

Oh man, I stand corrected. Sorry for the misinformation, I thought it included Emergency Med CPT codes 9928x as well. I guess not. I just looked it up to verify. Thanks!

 

[Buckeye1992]

Does this affect all TH contracts? I thought I saw this was for 18 states so wasn’t sure.

 

[hundreddaysoff]

Are there any EM groups in the country where the docs have chosen to do their own chart coding and then keep the money they would otherwise pay coders? Seems like this is the best way to give us skin in the game for this problem. Office-based docs seem to do their own coding sometimes so it can't be impossibly hard.

Learned a lot from ShockIndex's posts in this thread. It disturbs me that the words I write in my chart, for whatever original patient-care-based reason of my own, can be twisted through the funhouse mirror by TeamHealth/their coders/possibly their secret contract with my HCA hospital and could conceivably result in the feds knocking down my door and taking all my money. I know it's not gonna happen, but still disturbing.

 

[gamerEMdoc]

Are there any EM groups in the country where the docs have chosen to do their own chart coding and then keep the money they would otherwise pay coders? Seems like this is the best way to give us skin in the game for this problem. Office-based docs seem to do their own coding sometimes so it can't be impossibly hard.

Learned a lot from ShockIndex's posts in this thread. It disturbs me that the words I write in my chart, for whatever original patient-care-based reason of my own, can be twisted through the funhouse mirror by TeamHealth/their coders/possibly their secret contract with my HCA hospital and could conceivably result in the feds knocking down my door and taking all my money. I know it's not gonna happen, but still disturbing.

We did a rural community EM month in my residency and the group there did their own coding. They dictated at the time, and on the patient's paper chart (where they placed orders for the unit clerk) the last page was a coding sheet. Mind you, this was over a decade ago, I'm not sure what they do in the era of EMRs. Several of our residents went and worked there afterwards, it was a lucrative group. The docs were all well trained in coding. I actually learned quite a few tips while I was there.

 

[hundreddaysoff]

Does this affect all TH contracts? I thought I saw this was for 18 states so wasn’t sure.

My read is it affects most but not all contracts, so probably more than 18 states. Tidbits from an email sent to all TH docs last week by CEO Leif Murphy:

"""
A year of negotiations concluded with United unilaterally terminating the majority of our contracts across the country effective October 15, 2019, when we refused to accept a 30% reduction in our long-standing network rates.

...

At our net margin of less than 1%, United’s demands will require significant shared sacrifice from each of us across TeamHealth. Applied to wages alone, our concessions would equate to an impractical pay cut of over 6% for our physicians and senior leaders in a tight market for emergency medicine physicians, anesthesiologists and leadership. Since that is not realistic, we will scale back other expenses that include benefit eligibility thresholds, scribes, continuing medical education (CME) and national meetings. We will also have to implement back office and overhead reductions of over $20mm. With these initiatives, we anticipate reducing the wage component to under 4% on average for physicians and 5% or less for senior leaders, with the final impact to be determined as our negotiations and litigation with United advance.
"""

This all takes effect in July and TH is making us all sign a new contract agreeing to the pay cuts.

Not sure what "4% on average" means. Why don't they just cut every TH doc's pay by exactly 4%? Seems to leave wiggle room for TH to accomplish other regional goals by cutting pay by different amounts in different locations.

 

[deleted109597]

Are there any EM groups in the country where the docs have chosen to do their own chart coding and then keep the money they would otherwise pay coders? Seems like this is the best way to give us skin in the game for this problem. Office-based docs seem to do their own coding sometimes so it can't be impossibly hard.

Learned a lot from ShockIndex's posts in this thread. It disturbs me that the words I write in my chart, for whatever original patient-care-based reason of my own, can be twisted through the funhouse mirror by TeamHealth/their coders/possibly their secret contract with my HCA hospital and could conceivably result in the feds knocking down my door and taking all my money. I know it's not gonna happen, but still disturbing.

There are plenty of groups that do their own coding. Some do a good job and keep that money. Others do a terrible job and earn less than they would paying coders. It all comes down to the docs.

My read is it affects most but not all contracts, so probably more than 18 states. Tidbits from an email sent to all TH docs last week by CEO Leif Murphy:

"""
A year of negotiations concluded with United unilaterally terminating the majority of our contracts across the country effective October 15, 2019, when we refused to accept a 30% reduction in our long-standing network rates.

...

At our net margin of less than 1%, United’s demands will require significant shared sacrifice from each of us across TeamHealth. Applied to wages alone, our concessions would equate to an impractical pay cut of over 6% for our physicians and senior leaders in a tight market for emergency medicine physicians, anesthesiologists and leadership. Since that is not realistic, we will scale back other expenses that include benefit eligibility thresholds, scribes, continuing medical education (CME) and national meetings. We will also have to implement back office and overhead reductions of over $20mm. With these initiatives, we anticipate reducing the wage component to under 4% on average for physicians and 5% or less for senior leaders, with the final impact to be determined as our negotiations and litigation with United advance.
"""

This all takes effect in July and TH is making us all sign a new contract agreeing to the pay cuts.

Not sure what "4% on average" means. Why don't they just cut every TH doc's pay by exactly 4%? Seems to leave wiggle room for TH to accomplish other regional goals by cutting pay by different amounts in different locations.

For the record, Envision just sent out an email basically implying that belts need tightening as well.

 

[RustedFox]

For the record, Envision just sent out an email basically implying that belts need tightening as well.

This means they'll fire some useless admins and make the remaining admins do more work, right?

 

[southerndoc]

We pay our coders something like $1 per chart. It is not worth my time nor worth the risk for me to code it myself. At least with a third party coder, you can use it as defense that there is no incentive for them to upcode your charts. They get paid the same amount per chart whether it's critical care, level 5, level 1, whatever.

 

[ShockIndex]

We pay our coders something like $1 per chart. It is not worth my time nor worth the risk for me to code it myself. At least with a third party coder, you can use it as defense that there is no incentive for them to upcode your charts. They get paid the same amount per chart whether it's critical care, level 5, level 1, whatever.

Amen. Unless you are savvy, coding your own charts is a money loser and liability magnet. It’s like flying a plane, don’t do it unless you’ve been trained and know what your doing.

 

[deleted836128]

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.

Just curious, is this common place with everyone? I listen to heart and lungs on EVERY PATIENT, even a med refill. Not sure why... I am not trying to upcode anything; in my head it’s just doing an exam. It is just habit. Anyone else do this?