Insurance Quirks --> RE: physicals in the medicare population and fraud

[Guest guest]

Insurance gets so quirky.

Sent a 50+ gentleman for colonoscopy -- rectal bleeding, plus he was 50+.

Typically, insurance pays on the account better if there is a reason for doing a procedure (ie rectal bleeding).

I'm sure it's likely that insurance pays the GI doc better to do the colonoscopy for rectal bleeding rather than a screening colonoscopy.

But anyway, this patient's insurance pays completely for a screening colonoscopy at 50+, but the patient has a huge deductible that has to be met for the rest of his care.

So, of course, when the GI doc bills it as a colonoscopy for rectal bleeding, the patient gets stuck with the entire bill since he had to cover the deductible -- but if the GI doc had billed for a screening colonoscopy, it would have been completely paid for.

It's difficult to keep track of all these quirks.

Kind of like -- some insurances pay for a well child -- if so, I'll do the well child and throw in the sports PE form.

But some insurances don't pay for a well child, so it's cheaper for them to just pay the sports physical rate we have established which is a briefer exam.

But most patients are clueless (as am I) about what their insurance truly will cover.

Just some ramblings.

Locke, MD

From: [mailto: ] On Behalf Of Dr LevinSent: Tuesday, January 08, 2008 6:21 PMTo: Subject: Re: physicals in the medicare population and fraud

RE "I want a physical to manage my DM/HTN"

Careful -- some pts have different benefit plans. 1 price for the "well care physical" and regular (often with deductable) for regular care problems.

Once had a fellow yell and scream at me that his physical did NOT include by request review for his imitrex; felt like telling him that if not, then I wouldn't be writing for it (hadn't seen him before).

Matt

physicals in the medicare population and fraud

It's an education in itself for patients to understand what a physical is. Even if they say they want a physical or a "check-up" or schedule as a physical, I would still charge a 99211-99215 E & M if it is truly a problem oriented visit. I just couch the chief complaint in (my own) terms of what they really are asking for... "Manage my diabetes... Refill my BP meds... Cholesterol, etc..." Most of these are really "Manage my several comorbid medical problems." Now, if someone truly wants a physical, he gets a physical. I bet the person who got the 99215 for HTN, DM et al really did get a 99215 E & M (more likely 99214). If the correct amount of history, exam, and medical decision-making was done and documented, it's certain. What one CANNOT do is perform a physical and use the history, related exam bullets, and medical decision making, which is based on screening and prevention, to raise or affect the E & M level of a non-physical code. Jacques Guillot, MD

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