What Would You Do?

[aimhye]

Background: small independent specialty clinic switched the mid-levels from salary to wRVU based pay. It actually has worked out to be higher than previous salary but we are also seeing more patients. Recently a co-worker saw one of my patients and he coded a simple visit with minimal charting as 99215. I read and re-read the new AMA Guidelines on coding just to make sure I’m not missing something—or missing out on something! I am coding correctly. He up-coded my patient. Then I looked to see what he was billing generally and discovered he has coded and submitted hundreds of visits as 99215 for billing since January and all his new patients have been coded 99205. Still, I thought that would be ok, EXCEPT I now know his notes DO NOT support this level. He's not even close. Our visits get billed as we code them, I've been told our codes are not changed. Shouldn't Management know this is going on?? He sees about the same number and definitely the same complexity of patients as all the other mid-levels in our practice. He is the only one coding 99215/205, so I would think Management must know since they write the checks. I've talked to him generally about the wRVU values, but he claims to have no knowledge of any of it. I have to believe he will face an insurance audit at some point, right? I just don't think I can keep silent until then. BUT if Management knows what he is doing AND is turning a blind eye, will I not suddenly be out of a job? I mean, if I say something there’s a distinct possibility that they might just shoot the messenger. What would you do?

[ventana]

Stop calling a PA “mid level”

 

this is not your battle.  But he is dragging you into it. 
 

you eventually will be measured against this person and told to produce more.  Sucks but everyone likes making money. 
 

only way I can see out of it. Volunteer to do a one hour lunch talk for the clinic staff providers. Educate them on the billing guidelines and hope logic prevails. 
 

 

FYI I was one of the most experienced PA in a small ER (with about 8 yrs). Could not figure out why I was bottom 1/3 on productivity till I watched a fairly new PA bill a level 5 visit on ankle sprain.  She documented a full ROS and full PE (like you would do for an annual H&p) while literally never stepping into the room or touching a patient.   Yes she had high RVU(highest in department) but that is fraud and I wanted no part of it.  After I left there was huge staff tornover and they fired the company.   
karma does come back yo get you. 
 

 

[aimhye]

Sorry, switched all the physician assistants, nurse practitioners and physical therapists (DPT) to wRVU based pay. Was just trying to capture "the group" without being wordy.

 

 

[CAdamsPAC]

4 minutes ago, aimhye said:

Sorry, switched all the physician assistants, nurse practitioners and physical therapists (DPT) to wRVU based pay. Was just trying to capture "the group" without being wordy.

 

 

Non-Physician providers, maybe. Not that titles truly matter to me.

[aimhye]

I think the focus of my post/question has changed to a different topic all together--I've written to clearly spell out who is involved in the pay structure change.

I'm not 100% certain the employer knows the situation, but if they do know and if I break up the party I'll be tossed for sure. I'd like to preserve my job based on current job market and all the posts I've read on here about the difficulties out there so I was looking for advice/options/experiences anybody has had on how to correct this. I think though my job might be untenable.

[rev ronin]

If you chart the same day, you get to count your charting, records review, and consultation time against the 40 minutes for a 99215 or 60 minutes for a 99205.  Thus, it's financially advantageous for practices to have horrible EMRs, but that's another story.  At any rate, don't assume each 99215 is fraudulent until you understand the 2021 coding changes, which have increased the number of 99215's I chart by about 5-10x.

[Arthropathy]

Don't worry about what others are doing as long as you feel YOUR compensation is fair. You literally have nothing to gain and only expose yourself to risk and workplace politics.

[aimhye]

Thanks Rev, I've read and re-read the guidelines for coding. Definitely time can drive the coding, but if relying on time it needs still needs to be in the note. Without time, our patient base just doesn't rise to the level of 99205/99215 complexity--most of our visits are 10 to 15min maximum. It would be, how does Medicare put it--logistically impossible to achieve 9 of 39 visits a day at a 99215 level. That's only one example of what's going on. And yes, with the new coding guidelines it is much easier to achieve a higher code without the insane requirements we used to have to document. I'm not saying 99215/05s aren't justified. We shouldn't be leaving anything on the table. I do know my coding.

Thanks Arthropathy, I've had that thought also, to just let it be, let him dig his own hole. In the meantime I've decided tonight to take the attitude of "the best time to look for a job is when you already have a job". 

[Boatswain2PA]

5 hours ago, aimhye said:

Sorry, switched all the physician assistants, nurse practitioners and physical therapists (DPT) to wRVU based pay. Was just trying to capture "the group" without being wordy.

You have no need to be sorry.  You clearly communicated your point, and you used a clearly-established term.  If people get bent about it...well then that's their problem.
 

[EMEDPA]

13 hours ago, ventana said:

karma does come back yo get you. 

this! I used to work at a place that based a lot of our salary on RVUs. The guy who was always #1 in production had crappy notes, tried to see acute pts in the last 15 min of a shift, etc etc and made like 35k/quarter in bonuses. He was also the only PA in the group of 15 to ever get sued. 3 times. 

you can't write "consulted cardiology" and discharge a pt and just leave it at that and expect it to go well when the pt bounces back. 

who was it? what did they say? what is the follow up plan? 

[sas5814]

One of the hardest things I have learned (ok still learning) is to stay out of things I see that look wrong to me unless it is a hazard to the patient....particularly inter-office stuff. In my current job I see about 100 things a day that aren't being done right and if I chased after them all not only would everyone hate me I'd go mad.

Pick your battles so when you do it counts.

[aimhye]

Thanks EMEDPA and sas5814, I'm counting on Karma but sometimes its a long wait. In the mean time I've decided to just bide my time and begin my search. If management knows and if his SP knows, then I can look the other way also. The initial irritation has worn off as has my respect. Now that that is gone I can see my path a little more clearly.     

[CAAdmission]

8 hours ago, aimhye said:

Thanks EMEDPA and sas5814, I'm counting on Karma but sometimes its a long wait. In the mean time I've decided to just bide my time and begin my search. If management knows and if his SP knows, then I can look the other way also. The initial irritation has worn off as has my respect. Now that that is gone I can see my path a little more clearly.     

If they are defrauding Medicare/Medicaid, there are significant rewards for whistleblowers. 

[Cideous]

15 hours ago, CAAdmission said:

If they are defrauding Medicare/Medicaid, there are significant rewards for whistleblowers. 

And significant penalties for anyone with their name on the chart...

[aimhye]

hmm, do you mean me???? Because I discovered this mess only after this guy saw MY patient and coded a 99215 without any supporting chart note-it was a simple visit, chronic back pain no change--he signed off on the visit it wasn't my signature on that visit/code. Her visits with me have all been charted and coded appropriately. OR do you mean penalties on the charts signed off by SP? That makes more sense.

[sas5814]

each provider is responsible for coding on their own visits (only) unless there is some kind of conspiracy going on which is a different conversation. That's why the provider is the only one allowed to code a visit (though lots of back office nonsense is sadly common). So no...you can't get in trouble for someone else's coding. At one of my previous employers I had to threaten to call CMS because the billing office was changing my codes which is very illegal.

[aimhye]

Thanks for the clarification sas5814.