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08/22/2018 Kristin Happel
It's Time to Clean Up Our Act (Richard M. Hofacker, DPM)
Dr. Hofacker asks if the type of billing he saw on his patient's invoice from another podiatry office is the norm. No, it is not, at least not with podiatrists I bill for in various parts of the country. The Medicare allowed amount for a 11308 in Ohio is $190.97 when performed in an office setting. Leaving aside whether or not this was actually performed (I doubt it was, and should have been billed in the 1105X range, if at all), it would appear several things could be at play here to result in this patient having such an outrageous bill.
Without seeing the actual invoice, my guess is one of two things(or both) is going on: 1. The podiatrist she saw is not contracted with her insurance company, and she has no out of network benefits, so any dollar amount that is charged is allowed, and put as patient responsibility. Which means that this podiatry office does not have a "normal" fee schedule in place.
Every fee schedule I have ever seen will generally take the Medicare allowed amount, and charge 130-200% above that amount and round up. Some will take the highest allowed amount from whatever insurance companies they deal with, and round up. Thus, the 11308 should have been billed at $250-$380.
2. There is some charge or several charges on her invoice that were not allowed by her insurance company, and she is being billed for them (rightly or wrongly), at this not "normal" fee schedule. Some of you may remember the podiatrist from Wisconsin a few years back who made the news for crazily over-billing his patients. That didn't work out so well for him, as his license was suspended. Billing like this other office appears to be doing will eventually get them in trouble, is my guess.
Here is what I suggest, and wish every podiatrist would do: 1. Learn and understand your MAC and other insurance carriers LCD's and medical policies on the services you perform. While not every code you bill has a LCD or medical policy, many of them do, and you should know them. Ask yourself right now: "Do I know what my MAC's LCD is on RFC?" If the answer is "No", you need to look it up and learn it.
2. If you don't have the time or inclination to do the above, make sure your billing/coding staff does, so they can educate you as necessary.
3. Set a fee schedule that is reasonable, and within industry standards. If you choose to not participate with insurances, and run a cash only practice, again, be reasonable. If you are charging $1000 for a cortisone injection, you are out of line.
4. Purchase a Podiatry Coding Companion, such as the one published by Optum, and actually read it, or reference it when necessary. I have found that these are far better and more educational then any coding seminar I have ever attended. Some of you may find codes in there that you have been legitimately performing, but have not been billing for, and you can increase your revenue if you do.
5. Always remember that it is your signature that is on an insurance claim, and that regardless of whether you have a coding and/or billing staff at your office, that you are ultimately responsible for what gets billed out on that claim, and for how much. While there is no doubt that what insurance companies reimburse providers for are not fair amounts, it does not excuse a provider from rooking a patient with an outrageous bill, but it does illuminate the necessity of providers educating themselves on proper coding/billing practices. With all the potential changes coming for podiatrists in regards to how they bill, knowledge is power. Now is the time to get educated.
Kristin Happel, Podiatry Biller, Chicago, IL
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08/22/2018 Ron Werter, DPM
RE: It's Time to Clean Up Our Act (Richard M. Hofacker, DPM)
RE: It's Time to Clean Up Our Act (Joseph Borreggine, DPM) and Richard M. Hofacker, DPM From: Ron Werter DPM
Dr. Hofacker's comments remind me of something that a new patient's daughter related to me recently. 92 y/o gentleman brought in by his daughter came to me because they were outraged with the billing of the previous doctor. She received 2 checks from Anthem Insurance for the one visit of the previous podiatrist of her father totaling $1,550. She told me that she had taken her father to other podiatrist for the past 6 years for nails and corns.. On the last visit to this other podiatrist, when dad was called into the room as usual, she remained in the waiting room. He returned to her after his treatment 15 minutes later and said there's a different doctor. She found that peculiar since there was no notice that the other doctor had left or retired.
The father has an insurance plan that pays both in and out of network, out of net is 60/40. When she called the doctor’s office about the received checks she was told to just mail the checks to him and not to worry about the co-pay. She called and emailed the doctor’s office again about this and was told by phone and email not to worry because they would not be charged for the co-pay. She received a copy of the total bill the podiatrist submitted, from the insurance totaling $2,400. She was still outraged, called the insurance company and got from the insurance company an itemization of the doctor’s bill. He billed: 99204 IOV, 93923 non-invasive vascular, 11755 nail unit biopsy, 97598 debride skin and sub Q greater than 20 cm, 11721 mycotic toenails, 11056 debride corns. She asked me how could he have done all this in 15 minutes. I told her to request from the doctor a copy of his chart notes, which she did, and received. She showed me the notes and they appeared to be a what I would call a minimal routine care follow-up note. Minimal HPI, minimal medical history, exam was manually palpating pedal pulses with no mention of other class findings (which I guess he felt counted as a segmental vascular exam) no mention of a non-invasive vascular exam, and a dermatology exam which only noted which nails were mycotic. No other physical exams. No other E/M notations. Certainly not a 99204 initial visit which we cannot bill for because the exams are out of scope. No mention of nail biopsy or even the nail clipping sent to lab. No note of deep ulcer or deep debridement of same which he billed a debridement for.
How fraudulent is this. How unethical is this. Can someone like this just continue ripping off the insurance companies and the patients with no recourse? Someone like this is not going to police himself. Is there anything that can be done in cases like this?
Ron Werter, DPM, NY, NY
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