Our office has recently had an increase in the number of calls questioning bills.  This is in large part due to the fact that many insurance companies are putting more financial responsibility on their policy holders and covering less medical costs, which in this difficult economic time is placing financial stress on families.  Because of contracts between our office and the insurance company and the patient and the insurance company, there are many rules and laws regarding how to bill and collect payment.

The medical industry is different from most because we do not bill our customers directly.  We contract with insurance companies, who pay us what they feel is the amount due for certain services.  They also have contracts with their policy holders, which describe the payment responsibility for the patient.  We cannot alter the contract between a patient and their insurance company.  In fact, we do not know what the specifics are between a policy holder and their insurance company.  Each contract is different, even with the same insurance company.  For example, Blue Cross Blue Shield (BCBS) policies with different companies and with individual plans are different from other BCBS policies, even if they are both PPO or HMOs.  There are hundreds of various BCBS policies and each covers different services at various levels.  We cannot know what is covered, what is considered not covered at all, or what is considered patient responsibility until we receive payment for services from the company. 

We have attempted to discuss our policies on our website so that all patient families can know what our policies are, but we cannot list all covered or non-covered benefits because that is dependent on the contract between you and your insurance company.  Please read your policies and ask questions to your insurance company before visiting the doctor so you know your financial responsibility.

We follow strict coding rules and cannot upcode or downcode without breaking the law.  This means that a provider should use codes assigned to various sick and well diagnoses and level of difficulty of a visit.  Our electronic medical record helps to properly assign codes to visits, which is one reason there is a push by the government to get more physicians on electronic medical records.

One major issue we are seeing is that insurance companies are not all covering separate issues when seen on the same date of service.  Pediatric Partners follows the use of CPT as published by the American Medical Association. These CPT codes allow for the use of what is called Modifier -25 to identify separate preventive medicine service (well child exam) and a problem-oriented service (ear infection, hurt foot, earwax removal, etc) on the same date of service.

CPT is very clear on this point. In the guidelines preceding the Preventive Medicine Services codes, CPT states:

“If an abnormality/ies is encountered or a pre-existing problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate office/outpatient code 99201-99215 should also be reported. Modifier -25 should be added to the office/outpatient code to indicate that a significant, separately identifiable evaluation and management service was provided by the same physician on the same day as the preventive medicine service. The appropriate preventive medicine service is additionally reported."

Some insurance companies argue that if they were to follow these CPT guidelines physicians would game the system and would more often than not find a medical problem that would enable them to bill for both services, so they simply do not follow the guidelines at times. 

We argue that our primary motivation in this situation is to avoid inconveniencing patients who present with acute problems at a preventive care visit. Rather than asking them to return on another date to divide the services, we perform both and submit a claim for both.  We realize that this might take a few extra unscheduled minutes of our time, which can affect our office flow, but feel that it overall benefits families because a little longer wait time to avoid coming for multiple visits is preferable to most.  Insurance companies handle this situation of addressing multiple issues on the same date differently.  If payment for the second service is denied, we write it off, since physicians are usually prohibited under contract from balance billing the patient. If the insurance company says the payment is patient responsibility, it is insurance fraud for us to write off this charge.  Many families are upset with us when we do not write things off for them, but we simply cannot by law.

A new twist in the use of the Modifier -25 is that insurance companies are putting this cost to the consumer, which is what leads to many billing questions.  The extra cost often includes a second co pay on the same day of service, since multiple issues were covered on that date.  Please understand that it is your insurance contract that requires you to pay this portion, not our office specifically.  Again, it would be insurance fraud for us to write off this portion of the charge, so we will not.

Unfortunately, because of your insurer's payment policy, in some cases we may have to complete your wellness care and your illness care in two separate visits to allow appropriate billing. If you have a health problem you want to discuss with your doctor during your well visit, the doctor may decide to treat that problem and ask you to schedule another appointment for your well visit.  If the additional concerns are not urgent, you will be asked to schedule a separate visit to have that problem addressed.

Please understand that we will work with you to the extent that our contracts allow, but we are also a business and in these tough economic times we must be able to cover our increasing costs.  Our rent increases yearly, our office staff and nurses salaries increase yearly.  Vaccine costs are outpacing reimbursement rates.  Malpractice costs are climbing.  Costs to buy and maintain our electronic medical record and website to best serve our patients are substantial -- a major reason that few physician offices have electronic medical records.