There might be something to this but on the whole for practices it has been an unstated fact that for years doctors have under coded so as not to delay payment, especially on the 99213 office visit.  Prior to using electronic medical records and billing, substantiating a higher pay and code could be cumbersome and doctors all want their cash flow so they took the less payer of a standard extended office visit that added no complications.  There’s something to be said for that as it all usually took was for a few claims to get stalled out there with questions on a review of systems, HP&I and the time to get paid could go up to 90 days or more.  It was a paper shuffle. 

Now, with electronic medical records it is much easier and efficient to supply the additional information to justify the “real” and legal time they spent with the patients, so guess what, reimbursements went up.  Way back in the early days of EMRs I showed doctors how to do this and it’s legally paid for their time without claim delay with technology versus the old methods and reliance on super bills for all of it.  The change with removing consult codes too had some impact as well and insurers still honor those codes where Medicare does not, a few more complexities to mention. 

Medicare Eliminates Consultation Codes in 2010 – Adds Modifier to Distinguish Providers

Now back in September we had this come out to where HHS and DOJ said doctors and hospitals were cheating out there as the expenses on paying claims higher and were growing?  There was nothing specific referenced here either, so what big cases of fraud were found or what doctors were cheating?  This did not go over well at all and most all in tech saw it as a political “nervous” type of statement with stuffing something out there, which I thought too.  Here more on that and it really showed signs to me of some digital illiteracy at work and sometimes it’s maybe best to be quieter. HHS has their new software working and it’s doing a good job finding patterns, etc. as straight out fraud should be caught and halted anywhere, and also have skilled analysts that can in fact determine where the false positives arrive as there will be those caught in the parameters of the queries, so again folks that know what they are doing to hash mark those as not real fraud. 

HHS and DOJ Send Letters to Hospital Trade Associations Warning of Gaming Billing System Via Use of Electronic Medical Records–Hospitals Just Learned How to Bill Better & Hired Consultants–Case of Being Algo Duped With Numbers?

It would be interesting to see what HCA has to say as they kind of talked way up front about billing making their profits for them.  They must have better model and algorithms builders over there if in fact their billing is all accurate..and well..that’s another issue too…what is the perception of correct in many claim varies.

How is HCA a For Profit Hospital Chain, Making All That Money–Billing in the ER a Contributing Factor for Reimbursements–The Algorithms Move Money and Created Some Very Large Profits And Others Generated ER Care Parameters for the Facilities

You also have the Medicare contractors which are usually a subsidiary of an insurance company so they want to make a profit so you may not see as much auditing going on there sometimes too as the insurance company may own yet another subsidiary that is a billing clearinghouse too, so again they look for higher numbers as they are for profit.  We come back to the HHS auditing software as probably the best unbiased tool out there. 

Is Medicare Saving Money And Cutting Costs? It Depends on the Day of the Week and What Article You Happen to Read…

Medicare itself has some complicated algorithms for establishing hospital compensation that have come under fire from time to time.  Also worth noting too is the fact that the algorithms calculated by Medicare are largely created by information that is provided by health insurance companies who are Medicare contractors,

Insurers Made $450 Million with Interest Income by Holding Medicare Funds for Around 46 Days Before Releasing Payment

So, let’s see what “coding day” does here:)  The portions to really look at though are the automated systems used by hospitals I would think and a lot of 3rd party consultants come into play there as well with “their”coding suggestions and suggest parameters for hospitals to use, and not the EMR itself.  Prime Healthcare has been one company that has fallen under investigation a few times.  BD 

Federal officials worry that EHRs are being used to up code levels of treatment, resulting in higher than warranted reimbursement. “Invited speakers will discuss key issues such as the impact of EHRs on high quality clinical care, provider efficiency and coding, as well as coding challenges and opportunities facing various groups, including hospitals, clinicians and other interested stakeholders,” according to the agencies.

Speakers at the session will represent the American Hospital Association, National Association of Public Hospitals and Health Systems, American Medical Association, American Health Information Management Association, Electronic Health Records Association, American Academy of Family Physicians, Association of American Medical Colleges, Federation of American Hospitals, Association of Academic Health Centers, and Healthcare Information and Management Systems Society.


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