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Down-Code Billing issue

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So I just recently learned that the billing department at my current employer has been downcoding almost 2/3 of my patient visits - and it is completely arbitrary.  Patient's who are billed based on time (i.e. 40+min for a 99215) down-coded, while a single narcotic refill appointment left alone...

I mentioned this to the clinic administrator who stated she would look into it - and basically billing was going far beyond their pay grade to downgrade billing to pre-empt the insurance company from downgrading themselves.  For a bit of background one of the major insurers in our area is downcoding based on diagnosis only and not actually auditing the visit - completely illegal and it's being taken higher and higher within the state AG.

Getting back to me...normally I wouldn't give a rip about this - the company can do what it wants - except that approximately 1/3rd of my income is RVU based bonuses (another issue entirely).  Just for the month of August I have calculated that I lost approximately $1200 in bonuses, and who knows how long this has been going on.

I am currently waiting to hear what they are going to do about the lost income, but I have a feeling that it is going to be a "oh, this was a mistake, but hurt the clinic's income too so it's all even."  Something I'm curious about is whether I am the only provider this has been happening to or is it all 32 providers we have...because that could be HUGE $$$$$ lost!!!

I am posting this for two reasons:

1. if anyone has thoughts on next steps: try to claw my money back, let it go, dealbreaker and start polishing the resume?

2. this was ONLY caught because I keep track of my RVUs and the number of patients I see per month.  My RVU/patient visit has been dropping significantly over the last 3-4 months which I initially attributed to other causes, but as it kept happening I looked further...REVIEW YOUR NUMBERS PEOPLE!!!

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Wow, that sounds awful.  I agree that having 100% transparent access to billing and reimbursement is absolutely essential if your bonus structure depends on it.

My billers have all been very adamant that the provider sets the level, and they aren't entitled to change anything, but I don't know if that's convention, expectation, or law.

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As a matter of law nobody can set the visit level but the provider who performed the service. The billing folks CANNOT change the visit level. They can ask you to do it. The insurance company can refuse the payment at the level you set and pay at a lower level but what your billing people are doing is really inappropriate. What they are doing could be construed as fraud. Downcoding, at least with CMS, can get you in as much trouble as upcoding. The expectation is coding be accurate and not manipulated after the visit.

This is in CMS codes and regulations somewhere and CMS generally sets the rules and other follow . Do some research and you'll find it.

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My boss admitted and agreed that the billing department changing my codes was inappropriate and have "promised" it won't happen again...

I did some digging and arithmetic and found that I lost on average 8 RVUs per day 8/1-8/31.  I work 4 days per week so that is 136 RVUs in August alone (or $2040 in bonus)!  If you extrapolate with a more conservative number (I am the most productive provider within our clinic) for all 32 providers - let's say 4 RVUs - that is 2,176 RVUs in the month of August.  At a billing average of $100 per RVU - number given to me in the past by administration - that is $217,600 of billing just given away by the billing department.  But of course I'm assuming that I was NOT the ONLY provider this was happening to, which is something I have not been able to verify yet.  Also, I do admit there is a difference between billing and collections, but this was rather eye opening!

And now for the real eye opening response:

"Good Morning [my name], 
I have discussed the details of your coding questions and bonus money in detail with the leadership team. 
We will not be changing the coding from those visits we discussed, therefore we will not be paying out any additional bonus money

Understand that when [*generic insurance company*] reduced your codes previously, we also did not ask for your bonus money back.

Thank you, 
[boss's name]"

All I can really say is "WOW!!!!" They admit an error was made that negatively effected my income, and trying to qualify it by bringing up an issue from the past that was an error by [*generic insurance company*].  Even more, they are intentionally misleading me, because I know that they filed a report with [*generic insurance company*] and the company reviewed the charts and agreed they made an error and paid the vast majority of the decreasing billing - therefore there would have been no reason to "ask for [my] bonus money back."

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Good grief.....

If you are on RVUs and they are downcoding your visits without your knowledge they are just screwing you. The reply was, in my opinion, intentionally threatening. Rock the boat and it can come back and bite you......

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I can clearly say that I have been rocking the boat for the last 3 months.  It all started with requesting a pay raise, and it's been problems since.  Things calmed down for around 4-6 weeks as I've been pretty content with now only working 4 days per week, so I've been keeping my head down and just cranking out the RVUs, but obviously grudges have been held.  I am currently polishing my resume in between patients this morning.  We'll see where things take me.

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Yea I'm with you. I have been doing the same since we took on a "strategic partner" and there has been change after change after change none of them good for the employees. After losing 50% of our APP staff in the UC they just keep making bad changes. I'm casually looking. They pay me very well but there is always a breaking point.

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Contact an employment law attorney.  If there was indeed a violation of the law by the company that negatively affected multiple providers, the local DA may or may not also be interested.  There appears to be enough money at stake to be worthwhile.

And if you have to disclose that you sued a former employer for legal wrongdoing... so what?  The places that will not want to have anything to do with you after that are the places who are likely to do that in the future.

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The only time I've ever seen down-coding is where the chart notes don't support the code. Here, if that issue ever comes up (and rarely does) I have the opportunity to amend the chart notes to create an agreement with the code. I've never seen a case where we had to down code.

If an insurance company is down-coding based on diagnoses, unless that is clarified in their contract, giving them the right to do that, then they need to be sued. But suing insurance companies is very hard. I started a case, but then my own lawyers suggested it would cost me 300K to complete the case and I may or may not win anything, I let it go. But there need to be some class-action suits to hold these bastards (insurance companies) accountable.

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My advice would depend on the market your in.  If you stir the pot big time and report them you will become persona non grata.

And if you are in a small market, word will get around and you will not find work.  Just something to think about before you go nuclear.   

Edited by Cideous

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Do they not also lose money by down coding your visits? i don't see the logic in sabotaging their bottom line to pay you less.

Edited by SCPA

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1 hour ago, SCPA said:

Do they not also lose money by down coding your visits? i don't see the logic in sabotaging their bottom line to pay you less.

They do, and it's not so much that I thought it was a sabotage or conspiracy...more that the billing department made an error that affected my income and the administrators will not make it right and instead are trying to make excuses that are ludicrous.

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On 9/19/2018 at 7:50 AM, sas5814 said:

As a matter of law nobody can set the visit level but the provider who performed the service.

just to give credence to this statement - I have spoken with an attorney who confirmed this statement.  There is also a Q&A on medscape regarding this as well.

I don't plan on suing my employer, but if not handled appropriately could come back to bite me where the sun don't shine.  May also consider using as grounds for severance package from current employer as I leave.

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On 9/23/2018 at 4:10 PM, SCPA said:

Do they not also lose money by down coding your visits? i don't see the logic in sabotaging their bottom line to pay you less.

What this means: If they re-code the visits up, they will keep the extra profit.  If they don't, he's expected to take the loss.

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55 minutes ago, ventana said:

any updates??

 

look 3 posts up for update and plans - but have fully accepted a new job as of today so I completely plan on using the illegal acts of the billing department and the employer changing my income without informing me as leverage when it comes time to discuss severance.

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13 hours ago, mgriffiths said:

 There is also a Q&A on medscape regarding this as well.

 

Think you could link this kind sir? 

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2 hours ago, mgriffiths said:

you need to have a login to see full "article," but <https://www.medscape.com/viewarticle/872465>

 

or just google: "medscape changing CPT codes"

This is an article that it pays to look at the comments:

Dr. Jonathan Anagnostou|  AnesthesiologyDec 2, 2016
What about clinical practices or health systems which employ certified coders?
 
  carolyn buppert|  Nurse Practitioner (NP)Dec 9, 2016
@Dr. Jonathan Anagnostou Yes, certified coders who are employed to code or to audit clinicians' coding would be in a position to code or to change a code prior to submitting for payment.
 
This is similar to what happens in our institution. The organization is also at risk  for billing submitted. CMS requires an organization to have an effective compliance program. So you can't say we told them not to. Most programs of any size audit notes and bills to make sure they are documented according to standards. On the other hand the organization should communicate if they are submitting bills that are different than what the provider submitted. 
Flag
 

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50 minutes ago, coloradopa said:

This is similar to what happens in our institution. The organization is also at risk  for billing submitted. CMS requires an organization to have an effective compliance program. So you can't say we told them not to. Most programs of any size audit notes and bills to make sure they are documented according to standards. On the other hand the organization should communicate if they are submitting bills that are different than what the provider submitted. 

Absolutely, and while the administration in my practice/clinic does "audit" charts - we have zero certified coders.  No one within the organization has the authority to change a CPT code other than the provider who originally decided upon the CPT code.

Even further, the organization I work for now has a "policy" stating that certain patient visits MUST be billed at a 99213.  I doubt it's legal to force a provider to use a specific CPT code as that effectively takes away their decision making in choosing the appropriate CPT code.  I'm not fighting it as it's not worth it and there are so many ways around it, but still remarkably goofy.  I understand the idea of not wanting to over code/bill, but at the same time it is extremely poor to under code/bill as it takes away money from the practice.  Just learn CPT coding and in general it is pretty straight forward.  For me, if I am uncertain if something is a 99213, ...4, or ...5 - I bill at the lower of the two levels I'm choosing between.

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40 minutes ago, mgriffiths said:

  For me, if I am uncertain if something is a 99213, ...4, or ...5 - I bill at the lower of the two levels I'm choosing between.

Undercoding is also fraud.  I suggest every provider have a good, working knowledge of coding and code AT the level of service provided, not above or below.  The funny thing is that it's often not what you think it might be.  Walk-in strep throat? 99214: acute illness with systemic symptoms (fever), started a new Rx (pen), so risk is well-met, assuming you did the appropriate H&P.

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Absolutely agree rev - few and far between for the instances I described for me, but in reality the likelihood that an audit will end in disciplinary action for undercoding vs. overcoding is vastly different.

Edited by mgriffiths

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51 minutes ago, mgriffiths said:

Absolutely agree rev - few and far between for the instances I described for me, but in reality the likelihood that an audit will end in disciplinary action for undercoding vs. overcoding is vastly different.

Also true; I don't recall ever reading any news article, nor do I know of any situations, where undercoding was actually punished.

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19 hours ago, mgriffiths said:

Even further, the organization I work for now has a "policy" stating that certain patient visits MUST be billed at a 99213.

We had a similar issue here in the UC where we were told we were expected to have 75% of our codes as level 4. I asked the VP who told us that to please write it down and sign it so I'd have a copy. That was a year ago and still no signed policy. I wonder why?

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