Thursday, May 26, 2011

Upcoding for Cash

Well Mr. Jones, that's the end of today's visit. That will be $95. Wait a minute. I asked you about that cough. That counts as a partial review of systems, so I can tack on another $7.50. I also checked your med regimen for interactions. That gets me $9.99. And I did establish that you know who I am, where you are, and the time and date. Partial mental status exam counts for $12.75.

You probably cannot imagine doing that to a patient who pays cash for psychiatric treatment, but that is exactly what happens after many physicians and other providers wrap up a patient encounter when a third party payer foots the bill. If the physician fails to squeeze the maximum blood out of the reimbursement turnip in a hospital or a large enough group practice, a coding specialist will jump in.

Don't get me wrong. I dislike Medicare and private insurance companies as much as anyone, but there is something particularly disengenuous about sticking it to them when we would never approach a patient with the idea of attempting to squeeze every penny we can out of them. Quite the contrary, I tend to look for ways to charge my patients less for more. For example, I could have increased my fees to cover all the phone tag with patients and pharmacies, mostly related to refills and cancelling or rescheduling appointments. But a few months ago a patient had the audacity to text me, I texted her back, and now I save countless minutes over lower tech communication by texting with patients, easily enough to allow me to defer a fee increase for a few more months.

It's fine for physicians to make sure someone pays them adequately, especially when financial incentives lead to improved care, but when you stick it to the payer, whether it's a big guy like Medicare or a little guy like your patient, you ultimately stick it to all of us who pay premiums.


  1. "...when you stick it to the payer, whether it's a big guy like Medicare or a little guy like your patient, you ultimately stick it to all of us who pay premiums."

    Don't forget, Pharma has perfected this strategy. Ever try to figure out the cost of Abilify or Seroquel XR? Fuggedaboudit. The answer you'll get is, "don't worry, it's covered on all the major insurance plans." In other words, neither the patient nor the doc need to worry about the cost.

    But someone has to pay, right?

  2. But it's not even that simple, Steve. After you order the Abiliquel or the Serofy the patient calls from the pharmacy to tell you it's not on formulary, or the pharmacist faxes you a toll free number you have to call RIGHT NOW for prior authorization. Never mind that it's too late to discuss a different, perhaps generic, drug with the patient. You can avoid these problems by handing the patient samples, or better yet by setting up your own in office pharmacy. And of course patients love those discount coupons that make the drug free.

  3. Or just give everyone Buspar.