Your Personal Health Record: Diagnostic and Financial - Part 1

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Your Personal Health Record: Diagnostic and Financial - Part 1

M.J. McKeown, MD, FACOG, FACS

There are many articles and books on the subject of keeping one's

personal health record. In theory the new national trend is toward

electronic medical records with some system of a nationally accessible

summary record. This summary record is supposed to contain essential

medical data on a person such that if they appear in a hospital

emergency room or a clinic they do not usually go to there will be a

basic amount of data available to tell the emergency room or clinic of

life threatening diseases, necessary medications or medical allergies.

There are many hurdles to overcome before this universal electronic

medical record is useful. There are so many hurdles that it may never be

as informative as now envisioned.

There are several personal medical record systems available. These

systems are designed for the user to maintain a written record of

illnesses, medications, treatments, immunizations, and imaging studies.

However none of the systems give advice, supply forms, or discuss

obtaining the essential language of all this information. This language

consists of the code number systems used by all of the business side of

healthcare. The physician does not tell the insurance company that a

wart was taken off your hand. The physician uses a code number for the

diagnosis of the wart and another code number for the procedure being

billed. The insurance company maintains a list of acceptable code

numbers for which they will pay a certain amount. The physician needs to

learn the combination of diagnosis code number and procedure code number

any given insurance company will allow for the treatment done. All

insurance companies do not use the same combinations. All insurance

companies change the acceptable combinations over time. All insurance

companies change the acceptable diagnosis code that will enable a

physician to get paid for a procedure done. This forest of codes and

charges that change with time means that the physician of today needs to

hire a skilled coder to get paid for what is done. The coder needs to

tell the physician what dictated verbiage needs to be in the medical

record to support the combination of codes used. It is not unusual for

an insurance company to change the requirements in any given situation

if they seem to be paying out more than they like for a given diagnosis.

The coder and the physician will discover this when the insurance

company sends them a bulletin or when a formerly acceptable charge is

denied.

There is another concept developed by the insurance company in the

payment for a procedure done. This is the term, usual and customary.

This is to allow the company to say that the amount they will pay for

any procedure is the usual and customary amount they have found being

billed for that procedure. Frequently the allowed amount varies by

geographic location in the country in general or varies between urban

and rural within a geographic area. Insurance companies by calling this

usual and customary do not hesitate to inform those covered by it that

the physician seen was charging more than the usual and customary and

thus imply the physician is overcharging. It is hard for a physician to

say to a patient that the amount charged for a procedure meets national

standards when the insurance company has just implied to the patient

that the physician is a cheat. It is informative to learn how the

insurance company calculates this magic dollar amount. In one documented

instance the procedure was as follows:

1. Gather all the charges submitted from a given geographic area for

a given procedure over a certain time period.

2. Sort these charges from least amount charged to highest amount

charged.

3. Select the first 100 charges beginning with the lowest and add

them together

4. Divide that by 100 and call that the usual and customary.

It is easy to see that this method will always produce a low end amount.

It is unlikely a patient will get involved in appealing a usual and

customary designation. However it is important that when an insurance

company says the physician exceeded the usual and customary a patient

knows that is an arbitrary number calculated to be as low as possible by

the insurance company so it can pay as little as possible for any given

procedure. However it is advisable for a patient to obtain and

understand the code numbers used by the physician when a bill was

submitted. It is also advisable for the patient to obtain the code

numbers used by the insurance company when they paid the bill. It can

happen that these code numbers are not the same. In one specific

instance the physician submitted code numbers for the multiple diagnoses

the patient had and then code numbers for the procedure done. The

physician linked a specific code number to a specific procedure and

charge. The insurance company picked out another diagnostic code number

from the list and linked it to the procedure done and announced to the

patient that they did not pay for this procedure for that diagnosis. It

was only by requesting the billing records from the physician that it

was possible to see what the insurance company had done. The insurance

company paid for the procedure when they were notified by certified mail

that their little scheme had been found out.

There is another reason to obtain a copy of the physician's written or

dictated and transcribed text describing the visit in question. Brief

mention was made earlier that the physician's billing adviser and clerk

at times would need to tell him or her what verbiage needed to be in the

record of the visit to justify the charges in case the insurance company

decides to audit the text to see if there is evidence of coding to

increase charges which does not seem to be supported by descriptions of

the visit or in the case of procedures the detailed description of the

procedure.

This all may seem a dance of subterfuge on the part of healthcare

providers. However if one examines the breakdown of the costs of

healthcare in the United States the first place the payors go to save

money is to decrease the amount they will allow for any given visit or

procedure. They are able to do this because they are the payors that

provide the income for any healthcare provider. If one looks at a health

plan with care there is usually a list of accepted and covered providers

for the plan. The discussion likely goes on to give a percentage of

payment of any given bill for an accepted provider and then a lesser

percentage or perhaps no payment at all for out of plan providers. There

is usually no mention of coverage for the provider entity's business

costs such as secretarial help, nurse help, technician help and etc.

However figures for one recent year show that the absolute dollar cost

of healthcare did not rise however the percentage of that dollar that

went to actual providers went down by 17% and the amount that went for

administration went up by 17%.

With all of these various financial forces at work and since they can

change from year to year or even month to month it is easy to see that

just finding out what the provider billed and what the insurance plan

paid does not tell the whole story.

Keeping an up to date personal health record for you and your family is

excellent planning. Having these available if you find need of

healthcare services away from your usual providers may be life saving.

The entirety of the health record will grow to be too large to always

carry with one. However it is wise to carry a summary of major

illnesses, major surgeries, medications taken and any medicinal or other

allergies.

The more extensive records with all the codes will keep a record of what

the system used in the codes it talks. The linkages of codes and charges

and payments will allow you to catch any misuse of the system by either

the providers or the entities paying the bills. Once you have all this

data it is easier to check with the coverage discussed in the insurance

policy and what you actually had to pay. Remember to always demand a

copy of the actual health care insurance policy not just some benefits

pamphlet provided. Once you have a copy of the actual contract then read

the fine print to be sure you understand the policies of the insurance

company. In regard to Medicare and other State or Federal health

insurance coverage be especially sure to read all the fine print. If the

private or governmental insurance companies you are involved with offer

to have you sign up to receive information bulletins be sure and do so!

Remember that the area of health care insurance is especially one where

Caveat Emptor (buyer beware) applies.

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Kathy Meade

Arlington Educational Consulting

http://www.vapcacoalition.org/

http://www.naspcc.org/

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entirely fat. Without a brain, you might look good, but all you could do

is run for public office.

~ Bernard Shaw