Sent a threatening letter from a company for too many 99214

[smalltownpsych]

Reading this thread for the first time and am so glad I have decided to go cash only with my new practice. On a related note, I had applied to be contracted with Blue Shield and was accepted but they wouldn't tell me what the compensation would be for the various codes before I signed so I declined. Is this a standard practice to get you to sign an agreement without telling you how much you would get paid? My recollection of Business Law 101 is that would probably not be an enforceable contract anyway, but they have more lawyers than I do, that's for sure.

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[splik]

Reading this thread for the first time and am so glad I have decided to go cash only with my new practice. On a related note, I had applied to be contracted with Blue Shield and was accepted but they wouldn't tell me what the compensation would be for the various codes before I signed so I declined. Is this a standard practice to get you to sign an agreement without telling you how much you would get paid? My recollection of Business Law 101 is that would probably not be an enforceable contract anyway, but they have more lawyers than I do, that's for sure.

it is NOT standard practice but it does happen. It is more common for them to credential you before giving the fee schedule but of course it is reasonable to see the fee schedule before signing. The fee schedule should be part of the provider agreement that you sign and you can try to negotiate.

 

[smalltownpsych]

it is NOT standard practice but it does happen. It is more common for them to credential you before giving the fee schedule but of course it is reasonable to see the fee schedule before signing. The fee schedule should be part of the provider agreement that you sign and you can try to negotiate.

Thanks for the info. Just dealing with these insurance companies gives me an icky feeling. It is scary going private pay only and I’m all in at this point, but at this stage of my career I feel that I shouldn’t work with people I can’t trust.

 

[WisNeuro]

it is NOT standard practice but it does happen. It is more common for them to credential you before giving the fee schedule but of course it is reasonable to see the fee schedule before signing. The fee schedule should be part of the provider agreement that you sign and you can try to negotiate.

Similar. BCBS included the fee schedule with all of the other contract paperwork when I credentialed with them. May just be a regional thing. All of the payers I am credentialed with have provided the fee schedule prior to signing anything.

 

[smalltownpsych]

Similar. BCBS included the fee schedule with all of the other contract paperwork when I credentialed with them. May just be a regional thing. All of the payers I am credentialed with have provided the fee schedule prior to signing anything.

They are probably just seeing if they can get away with it or don’t care if providers really join. If their contract providers are full, then they don’t have to pay anything. The more they do this the more people will be willing to pay cash so in the long run it will benefit me. I read an article recently about strategies insurance companies are using to dodge parity law and that as a result the number of cash pay mental health services continues to increase. i am beginning to think that I can collect two to three times as much by being out of network so will not have to work nearly as hard to make the same amount of money or get well-compensated if I am busy. Either way, it’s a win.

 

[Sushirolls]

Some of the insurance companies I paneled with didn't show fee schedules until after.
~2/3 showed it up front.

 

[MedMan80]

Got another one of these a few weeks ago, much more nicely written. Honestly this is incentivizing me to go into PP, but I will probably only start with a few higher paying insurances + cash

 

[splik]

Got another one of these a few weeks ago, much more nicely written. Honestly this is incentivizing me to go into PP, but I will probably only start with a few higher paying insurances + cash

getting letters telling you you're billing practices are cutting into their profits is incentivizing you to accept insurance in PP?!

Where I am, Anthem flags anyone who bills more than 50 99214s in 6 months, or uses 99214 thrice for the same pt in a 6month period. Ridiculous. Even if the audit shows you are using the codes correctly, they will reduce your rate for 99214 to that of 99213 instead so the end result is the same. Many people are finding they are just downcoding them without even reviewing the records.

 

[WisNeuro]

Definitely sucks for the patients, but for the few insurances I don't take due to the hassle factor or terrible reimbursement, I'm just upfront on why I'm out of network when speaking to those patients. If you have a choice, choose another insurance plan. If you don't have a choice, complain to your employer for having such a ****ty insurance plan.

 

[whopper]

Obviously bill honestly. If they audit you and you were billing honestly you have nothing to fear. What I do to make sure we're meeting criteria is PHQ-9s and GAD-7s with all meetings in addition to the standard (MSE, ROS, etc). I also add a narrative of what's goin on with their life.

 

[Sushirolls]

Obviously bill honestly. If they audit you and you were billing honestly you have nothing to fear. What I do to make sure we're meeting criteria is PHQ-9s and GAD-7s with all meetings in addition to the standard (MSE, ROS, etc). I also add a narrative of what's goin on with their life.

Bill honestly only goes so far.

If you aren't billing based on time, they can spin things completely in their favor to say poorly billed, and therefore we are going to revoke X amount of dollars.

Have you ever played the billing game with other docs, have a progress note or new consult out for display in a medical group practice and had every one critique/rate its billing? Seldom are notes 100% agreement as 99214. And this variability is exactly what the insurance company, or perhaps a third party entity like Change Healthcare will hone in on. An insurance company will simply do it to claw money back and continue their bludgeoning of doctors. A 3rd party entity will do it to show/prove their worth as a third party entity and they deserve to exist because they find X amount of "bad billing" or "fraud dollars." They are motivated to find things to perpetuate their value and existence in the eyes of an insurance company. Besides the obvious optics of distancing the insurance company from being the bad guy, "It wasn't us, but this quality, professional 3rd party company that says you are the bad billing doctor - don't blame us - blame them and their years of quality analytics, and sue them if you must sue any body."

 

[smalltownpsych]

Obviously bill honestly. If they audit you and you were billing honestly you have nothing to fear. What I do to make sure we're meeting criteria is PHQ-9s and GAD-7s with all meetings in addition to the standard (MSE, ROS, etc). I also add a narrative of what's goin on with their life.

You are so much more reasonable about this than I am. My attitude is "f' those people". Seriously though. There is a concerted effort to undermine what we do by making us need to justify it to people who are just trying to get money from our patients and us in the name of improving things and making sure that we aren't just greedy people taking advantage of our patients. This new no-surprises law is a great one. The insurance companies and CMS cook up this complicated billing scheme with all of these stupid codes, tell us this is how we have to do business and then blame us for confusing our patients so that we could screw the patients. My patients were never confused by me and never have been. I tell them how much it costs and they get it. On the other hand, when they try to understand their insurance policy or god forbid talk to their insurance company, they are going to need twice as much psychiatric care.
Just to be clear this rant wasn't directed at your post. It just doesn't take much to get me started on this stuff.

 

[nexus73]

You are so much more reasonable about this than I am. My attitude is "f' those people". Seriously though. There is a concerted effort to undermine what we do by making us need to justify it to people who are just trying to get money from our patients and us in the name of improving things and making sure that we aren't just greedy people taking advantage of our patients. This new no-surprises law is a great one. The insurance companies and CMS cook up this complicated billing scheme with all of these stupid codes, tell us this is how we have to do business and then blame us for confusing our patients so that we could screw the patients. My patients were never confused by me and never have been. I tell them how much it costs and they get it. On the other hand, when they try to understand their insurance policy or god forbid talk to their insurance company, they are going to need twice as much psychiatric care.
Just to be clear this rant wasn't directed at your post. It just doesn't take much to get me started on this stuff.

Insurance are the baddies.

 

[smalltownpsych]

Insurance are the baddies.

One thing I like about psychiatrists, they tend to get straight to the point.

 

[MedMan80]

getting letters telling you you're billing practices are cutting into their profits is incentivizing you to accept insurance in PP?!

Where I am, Anthem flags anyone who bills more than 50 99214s in 6 months, or uses 99214 thrice for the same pt in a 6month period. Ridiculous. Even if the audit shows you are using the codes correctly, they will reduce your rate for 99214 to that of 99213 instead so the end result is the same. Many people are finding they are just downcoding them without even reviewing the records.

I worry about not giving access to care to folks who really need it by going cash only

 

[WisNeuro]

I worry about not giving access to care to folks who really need it by going cash only

You could always volunteer at a free clinic if you are so inclined. Most places I've been have at least one in the metro that exclusively serves MH needs.

 

[calvnandhobbs68]

Got my most recent letter from Change Healthcare too (but for me they're now "partnering" with BCBS). Apparently I too should be billing 2.5% 99212s, 3.2% 99202s and 12% 99203s (who the hell is billing 99202 or even 99203 for a psych intake). Of course I'm billing like 90% 99214s and of course they still think I should be billing 50% 99214s. But apparently I should be billing 4% more 99215s lol.

 

[Mad Jack]

I got this too. My 99214/99213 was reasonably balanced but apparently I’m suppose to be billing at least some as 99212?! Who does that?

I’m afraid these averages are skewed by those who don’t know the rules and just throw 99213 on everything, to be safe.

There is almost no visit in psychiatric practice that would qualify as a 99212. A single med qualifies as a 99213.

 

[Mad Jack]

getting letters telling you you're billing practices are cutting into their profits is incentivizing you to accept insurance in PP?!

Where I am, Anthem flags anyone who bills more than 50 99214s in 6 months, or uses 99214 thrice for the same pt in a 6month period. Ridiculous. Even if the audit shows you are using the codes correctly, they will reduce your rate for 99214 to that of 99213 instead so the end result is the same. Many people are finding they are just downcoding them without even reviewing the records.

This should be a contract violation on the part of the insurance company. They are literally just stealing money.

 

[calvnandhobbs68]

This should be a contract violation on the part of the insurance company. They are literally just stealing money.

Yeah I've heard this happening with other insurers too though, I think Cigna or Aetna around where I am was doing this a couple years ago auto-downcoding visits to 99213s.

There is almost no visit in psychiatric practice that would qualify as a 99212. A single med qualifies as a 99213.

It's even higher, if it's a prescription med that counts as 99214 level medical decision making, so gives you "moderate" risk of complications and/or morbidity/mortality of management. 99213 is "take some OTC melatonin to help with your sleep" and 99212 is like, you've got some rhinorrhea, it's probably a URI and it'll get better by itself, come back if it doesn't....it's honestly even hard to get down to a 99212 level of coding because it requires purely 1 "self-limited"/minor problem with basically no action taken ("minimal" risk of morbidity).

 

[nexus73]

The people billing 99212 and lots of 99213s are either employed with no incentive to code correctly, or woefully unaware of proper coding and being under compensated for expertise.

 

[lockian]

Recently got a letter from a third party company (don't recall the name), comparing my billing codes with others of the same specialty. While it was worded as nicely as possible it indicated that i was billing more 99214 and less 99213 than the average joe psychiatrist. It also suggested I could be audited if this trend continues, it did not specify any insurance companies. I work in a rural hospital and see the sickest of the sick kids, comorbidity is the rule. I'm not concerned my notes won't hold up to scrutiny, but something like this definitely wants me to look at cash only or cash plus 1-2 insurances for future opportunities. Anyone else see such letters?

I got a letter like that from an insurance company. My boss’ directive? To ignore it, because everyone gets them.

 

[Sushirolls]

Aaaannnndddd, got another letter.

Who is billing 99213 at all? And even 99212?

Last I saw, feds didn't block the UHC acquisition of Change Healthcare, so it will move forward.

 

[nexus73]

talked to cardiology yesterday they said every follow up is 99214. Everyone has “at least 4 problems”. 15 minute follow ups BTW.

 

[docksan]

Vast majority of psychiatric visits will be 214 by default if they have more than one diagnosis.

 

[MedMan80]

I got another letter a few weeks ago, worded neutrally...went straight to the trash and i had a warm and fuzzy feeling

 

[splik]

Last I saw, feds didn't block the UHC acquisition of Change Healthcare, so it will move forward.

It already has!

 

[B52slinger]

Does this happen with CMS (medicare/medicaid) as well or only a few specific companies?

 

[calvnandhobbs68]

Does this happen with CMS (medicare/medicaid) as well or only a few specific companies?

If the medicaid plans are managed by private companies or medicare advantage plans (which they are in many states) then yes. I've personally gotten a letter before from a managed medicaid plan.

 

[MedMan80]

No letters for >6 months. I wonder how much money they saved by folks down-coding, I know I didn't permanently change my billing approach very much.

 

[Sushirolls]

I only made extra sure my 99214 were 99214. ~85% +/- 4% or so is 99214.
I also relocated my practice, so just a matter of time before they resume, is my guess.

*oh, and that time I spent on documentation, if it was enough to ensure a time based 99214 I documented it that way.

 

[calvnandhobbs68]

No letters for >6 months. I wonder how much money they saved by folks down-coding, I know I didn't permanently change my billing approach very much.

lol I just got another one the other day, I'm pretty sure BCBS is gonna just keep sending them a couple times a year to me

 

[clausewitz2]

lol I just got another one the other day, I'm pretty sure BCBS is gonna just keep sending them a couple times a year to me

Figure it costs them maaaaybe a dollar a letter, so all they need to get you to do is downcode one 99214 that you would have billed to a 99213 over the course of the next year and it's fiscally worth it.

 

[MedMan80]

Figure it costs them maaaaybe a dollar a letter, so all they need to get you to do is downcode one 99214 that you would have billed to a 99213 over the course of the next year and it's fiscally worth it.

It's horrible but if i worked there or was a shareholder, would make the most sense to do this (albeit slimy)

 

[Sushirolls]

Change Healthcare is now owned by UHC, I wouldn't expect anything less.
UHC now employs more doctors than UHS, VA, Kaiser.

 

[Sushirolls]

The saga continues.
Got a voicemail saying they want a callback to confirm that the office received their last mailing from several months ago...
Anyone else getting calls now?

 

[calvnandhobbs68]

The saga continues.
Got a voicemail saying they want a callback to confirm that the office received their last mailing from several months ago...
Anyone else getting calls now?

lol why would anyone ever call them back? But no haven't gotten that yet, maybe they figure this is an even higher yield scare tactic.

If they want to audit they're gonna do it either way, I'm not gonna waste my time trying to convince you not to audit me.