You’ve Been Paid – What’s to Worry About? (More that you might think)

I’ve spoken with lots of providers whom I feel are not billing properly, either due to ignorance or sometimes deliberately attempting to get more money from an insurance carrier.  When I explain billing and coding and exactly what they are doing that is incorrect, the usual response is: “Well the insurance company is paying, why should I change?”  You know what – They’re right in that the insurance carrier usually is paying and quite well too, however what they do not realize is the information about those services they billing for can be requested AT ANY TIME by the insurance carrier.  The carrier has the right to request medical records to substantiate the need for the treatment long AFTER the claims have been processed and paid.

The following are three situations I see frequently that can come back to haunt a provider:

1.  Billing for an office visit EVERY single time they see the patient.  This is by far the biggest NO-NO, and carriers are catching on.  There must be a substantiating need for a separate office visit, and that can’t happen two to three times a week.

2.  Billing for a timed procedure that was only done for a short amount of time or not at all.  By far the biggest culprit is 97140, myofascial release.  The rule is you must provide the service for at minimum 8 minutes to bill 1 unit of a timed based code.  Giving the patient a 2 minute neck massage is not going to cover it.  Did the procedure but didn’t document the time on your notes?  Get audited and you’re giving the money back.

3.  Never changing a patient’s diagnosis.  I’ve literally seen patients that have been treated for years for the SAME condition.  Again the provider will say – well they keep paying. This creates two conditions.  Either: A.  You are treating the patient and he is NOT GETTING BETTER! Or B. You are treating the patient for one thing, but submitting a claim for something else.  The carrier requests the notes and/or sends a questionnaire to the patient, either way, and you’re going to be asked for the money back.

Audits, requests for records, are NOT GOING AWAY.  Mark my words – if you have been doing any of these three things, it’s only a matter of time before it comes back to haunt you, and I don’t want to say, I told you so.

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6 Responses to You’ve Been Paid – What’s to Worry About? (More that you might think)

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  3. Angelica says:

    I was wondering why you can’t bill insurance for each office visit? If you see them for acute pain and recommend they come in 2-3 times a week for two weeks, you can’t bill for that? Just curious.

    • Mori West says:

      You can’t bill each time they come in because there is a built in office visit code included with the first 15 min of acupuncture. You must go beyond the typical pre-service work to bill an office visit code in addition to the acupuncture. It doesn’t matter if it’s acute, chronic, its about doing the work and documenting the work ABOVE AND BEYOND the typical treatment. So when do you bill an OV – WHEN YOU DID THE WORK AND CAN PROVE IT. The first visit, certainly, when there is an exacerbation and/or flare up that would necessitate you evaluating the patient’s systems again, making changes to the treatment plan in place, considerable medical decision making AND of course documenting objective findings found during this new evaluation. I am going to be frank, the fact that you give the example that the patient has acute pain and comes in 2-3 times a week for two weeks then ask why you can’t bill insurance for each office visit gives the impression you don’t know why you are billing an office visit in the first place- it isn’t because he “visited your office”. I will also tell you office visits are HIGHLY abused by acupuncturists and are under the radar of alot of carriers. YOU MUST DO THE WORK TO EXPECT TO GET PAID FOR IT.

  4. Sabin says:

    I am working with a company that insists that I down code for services that I do, because they don’t want to adjust their books later for the un-paid services (I am only billing what I have done), ethically it feels wrong… is it just me?
    I feel that insurance companies need to see what an acupuncturist does, reflected in chart notes, supported by notes with time stamps. Why down-code?

    • Mori West says:

      This is VERY interesting. Are you IN network or OUT of network? If this is an IN network situation a lot of carriers have a per Diem rate, so you bill what you do but they only allow the first 15 min of acupuncture, and/or they don’t allow office visit codes. If that is the case, (I am assuming you are IN network because how is the office sure the charges would be unpaid?) it’s not as much ethics issue, in a sense it’s a business decision. NOW, it would be an ethics issue if they weren’t sure what was allowed (because they are out of network, don’t have contracts, and fee schedules to go by, etc).

      With that in mind I 100% agree with you wholeheartedly that you should bill your regular rates AND bill what you do so that carriers have a true sense of what is being performed and at what rate. Any decent software can be set up to take In network rates into account and automatically does a write off based on the negotiated rates. Viola – you’ve accurately reported your charges, and the software took into account the negotiated reductions. NOW – I can tell you why the office doesn’t want to do it – the A/R report. When they run an A/R report of what they have outstanding, it isn’t a true picture, the differences aren’t taken off until the payment comes in. SO – they run a report and it says they have $10,000 outstanding, however it is clear that those are your regular rates NOT your contracted rates, so it’s not accurate. You solve that problem by going back and creating an average. Based on past performance of billing our regular rates, but receving contracted payments we collect 60% on our accounts receivable. It fluctuates a bit, but its usually accurate enough for most offices. It’s unusual for an acupuncture office to want such accuracy. Is this an acupuncture clinic? Or a multi-specialty clinic? I bet its the latter.