The 'game' of healthcare payments
Most medical professional organizations will have tips for their members on how to fill out an insurance claim form. Anyone eligible to submit a HCFA claim form for any service can learn tricks to get better reimbursement, better ways to "code" the services they perform. This may be one of the biggest problems with U.S. health care. It is played like a game with no clear rules where every player will feel the loser at the expense of another player. Even the most noble practitioners will feel they must stretch codes on claims just to maintain a viable practice because payors have had to reduce reimbursement due to rampant "up-coding" on claims. Despite what can be seen as the most sincere, and at the same time, the most devious attempts to "make it right," it will never be fair.
If one's entire task in practicing medicine (or chiropractic) is to get paid more for doing less, the means is available.
How do payors likely respond to the "you should be billing 4 modalities on every claim" advice? They can try and "bundle" modalities and suggest one is inclusive or redundant to the other, they may even have expert medical opinion to justify the action. This option may not work much anymore - just ask United, Aetna, and half the Blues.
Payors can scrutinize claims histories and single out practitioners that always bill 4 modalities on every patient. This is costly, but it often works. But, it's very difficult to prove anything when fraudulent claims are accompanied by fraudulent patient records.
Another option is to further limit the benefit from 4 modalities to only cover 3, or 2. The patient will lose most by maybe not getting care they need. Practitioners then feel they can't perform useful services because they're not paid. Payors then become at risk for the creation of state or federal legislation that limits restricted coverage.
Finally, the payor can reduce reimbursement so that paying 4 modalities becomes like paying 3, or 2. They'll justify the reduction by presenting plotted charts to show how over 2 years the average clinic visit was 2 modalities and now it averages 4. The "good" practitioners are penalized and are essentially forced to join the "always bill 4" ranks. Practitioners can then possibly respond by billing additional codes and services that don't fall under the 4-modality limit, thus turning the "game" back over to the payors.
If one's entire task in practicing medicine (or chiropractic) is to get paid more for doing less, the means is available.
How do payors likely respond to the "you should be billing 4 modalities on every claim" advice? They can try and "bundle" modalities and suggest one is inclusive or redundant to the other, they may even have expert medical opinion to justify the action. This option may not work much anymore - just ask United, Aetna, and half the Blues.
Payors can scrutinize claims histories and single out practitioners that always bill 4 modalities on every patient. This is costly, but it often works. But, it's very difficult to prove anything when fraudulent claims are accompanied by fraudulent patient records.
Another option is to further limit the benefit from 4 modalities to only cover 3, or 2. The patient will lose most by maybe not getting care they need. Practitioners then feel they can't perform useful services because they're not paid. Payors then become at risk for the creation of state or federal legislation that limits restricted coverage.
Finally, the payor can reduce reimbursement so that paying 4 modalities becomes like paying 3, or 2. They'll justify the reduction by presenting plotted charts to show how over 2 years the average clinic visit was 2 modalities and now it averages 4. The "good" practitioners are penalized and are essentially forced to join the "always bill 4" ranks. Practitioners can then possibly respond by billing additional codes and services that don't fall under the 4-modality limit, thus turning the "game" back over to the payors.
posted by nawledge at
1:32 PM
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