How Your Health Care Works, Part II

Now that we know who makes the money, how it is supposed to come in and who pays it, lets talk about the billing process. As I said in part I, only face to face interactions are paid for. When these interactions happen two codes must be submitted to the insurance company, an E&M code (evaluation and management) and a diagnosis code. The E&M code is intended to represent the type and intensity of the visit, type meaning; procedure, counseling, diagnostic etc and intensity meaning low such as a cold, or high such as a person with heart disease, kidney disease (or other chronic diseases) who need complex medical management. In the PCP office the most common codes are 99211, 99212, 99213, and so on (99215 being most complex). Then a diagnosis code must be assigned for the disease or symptoms. Here is where it gets weird, as a PCP if I use the diagnosis code for depression I generally wont get paid because that is for mental health providers, I can treat depression, as you know most depression is treated by the PCP in this country. I must then bill for a symptom related to depression. This is one of hundreds of rules put into place to delay or deny payment, and the rules change as we go and are different with different insurance companies. Additionally each code requires a note that shows I did a certain amount of work. For a 99213 I must ask and record; history of presenting illness, relevant associated symptoms, review past history, and examine a certain number of body systems!!! This has nothing to do with whether or not I believe this to be medically necessary, but if I bill a 99213 and do not live up to the insurance company requirement (standards are often set forth by Medicare) I can be charged with insurance fraud!!!! Note, that when you bill the higher more expensive codes on a more regular basis you are often examined, in two years I was requested (and required really) to send copies of several notes to prove that I had done what is required to meet the standard of a particular code!!!!!
Here is how you will get paid, for every E&M code each insurance company has a MAB (maximum allowable benefit) this is what they will pay you for this code, note however that this amount is different with each practice and it is actually illegal, that's right against the law, for me to ask one of the other practices in town what such and such and insurance company pays them for a particular code. Basically they pay you what they say they will pay you, if you don't accept it they will remove you from their preferred provider list and tell all of their patients that you are a non covered physician (thus you will lose significant business). Now it gets even more complex, say your bill for service was $75, the insurance company says that their MAB for that service is $60, then they say out of that we will cover $45. Your job now is to write off $20 and try and collect the additional $15 from the patient (or secondary insurance if they have it) you are in breach of contract if you try to also collect the $20 which the insurance company said was not included in MAB. You may bill whatever you want, you will get paid what they say they will pay you!!! Your prices have nothing to do with what it cost to do business, it has to do with how much they will pay you.
Finally, secondary insurance. You may bill the remainder of the bill (not the $20 you wrote off mind you) to the secondary insurance if there is one. First you have to receive the report of payment from the insurance company, then you have to take a black marker and cross out all the peoples names on this report that are not part of this interaction, finally you must print a paper bill on what is known as a HCFA form and attach all of this together and mail it to the secondary insurance. Note, if you try to bill the patient for this amount when they have secondary insurance you are again, in breach of contract!!!! The time to bill and get paid for one 15 minute interaction in this manner is about 25 minutes for the billing and as much as 200 days to get paid (each ins co has 90, but you have to wait for that report before you can bill the second person and it takes time to dig up the information three months later). So for my $75 bill, for which I will only get paid $60, I had to wait the better part of a year, pay my billing person $11, and I spent money on postage twice, copying, printing etc. questions?