I will also bring to light that the quest for high gross collections can go awry. Be careful saying that someone is doing something wrong because their collections vs patient volume does not meet your expectations. One of the biggest threats to your well being in practice is over coding. The biggest examples are with Toenail issues, namely billing 11730's on patients without consents and documentation of anesthesia administration. The other is billing 99212 in lieu of 11719 which is generally uncovered or pays a whopping 17 dollars when it is covered vs around $60 for E&M code. But if you get caught you could be looking at paying back an extrapolated sum that will put you into poverty or send you to jail. I know of a few DPMs in this position as well. Over coding E&Ms can get you into trouble too, but that has not been a big target of the OIG in recent years. Another big issue is a 25 modifier on subtalar fusion for you arthroerisis. And similar issues for coblation. These are undefined procedures and essentially are unreimbursible by insurance so most people find "the best fit code", all of which is essentially illegal in the eyes of the OIG. Yes! taking care of patients can be illegal.
I'm not saying that everyone who sees 25 patients a day and grosses 500K is doing these or other incorrect coding applications. But usually something is not right and at the very least , it is those on the high ends of the reimbursement per patient and total reimbursement curves that will get audited. You may pass, but you'll still pay in lost time and worry and aggravation. It is a shame when you have to pay to defend yourself when you have done nothing wrong. But that is the way it is and no proposed healthcare reform has sought to change it. They often spend more in fraud and abuse then they recover (If you look at the final rate of returned recoveries from contested audits).
Also note that about 22% of Meaningful use audits result in return of incentive funds (18 k for the first year less for subsequent years).
25% of Practices are Failing Meaningful Use Audits
But if you are thinking about starting a practice understand that the past administration sought to increase audits 5 fold and no one is proposing a change.
This post is one of the best I've read in a long time. Over the years I have been a hired consultant for insurance companies, and I have recently spent more time doing this since I really enjoy it.
Please don't listen to reps who tell you how to bill and please be cautious when attending seminars that tell you how to bill differently to make more money.
Your documention needs to support your procedure. You can't document that a wound is 1 mm in depth and then bill a 11043 which is debridement into muscle or fascia.
Every arthroreisis I see billed is either billed as a subtalar arthrorDESIS (without a modifier) or reduction of a talo tarsal dislocation. In my opinion billing either one of those is pure fraud. When using one of these devices you are performing NO parts of a subtalar arthrodesis. You are in the sinus tarsi and not in the STJ. Even billing as a reduced service is fraud. A talo tarsal dislocation is a traumatic event and not resolved with a device popped into the sinus tarsi. It may be a "hypermobile" joint or may be mildly subluxed, but it is NOT dislocated. Billing it as a reduction of a dislocation is fraud.
I also see a lot of docs billing a 11305,11306 and 11307 when trimming an IPK or keratotic lesion. The code is a shave of an epidermal lesion for biopsy and requires anesthesia. It's not for palliative care every few weeks.
The list goes on and on. And when I review these cases I often wonder how many times these doc HAVE gotten paid for a 10 procedure performing an arthroreisis and billing for a STJ arthrodesis.
I wonder how many times a doc has billed a 11305 and got paid for doing nothing more than trimming a lesion.
You can make a LOT of money being a fraud. Just be prepared to eventually go to jail. Read up on Dr. Young of Detroit who was making ridiculous money and got nabbed for 13.9 million. Read up on Dr. Monaco of Pennsylvania who was living high on the hog and got nabbed for over 5 million in fraud.
I've been in the business for quite a while. I know what it takes to make money. Any DPM who brings in one million by himself/herself is either a thief or one amazing individual.
Billing a million isn't that difficult. With today's reimbursement, collecting one million for one doctor is not an easy feat and would raise my eyebrows.
I know the math and it sounds easy. See 40 patients a day at 100 bucks a pop and work 5 days a week for 50 weeks and you've got a million.
When you get into practice and realize not everyone is seeing 200 pts a week and that reimbursements are low, you'll understand.
Be honest, do the right thing for your patient and you will make a nice income. Be a pig and a thief and you will make huge money, and then will get cocky until you lose everything and go to jail.
The OIG knows who to look for and what to look for. They take their time and an investigation can take years, because they want an ironclad case. And once they've got you......you're done.