Preventive labs vs diagnostic PLEASE ADVISE!!

[Pam Brooks]

Originally Posted by Skenyon

This is all the insurance companies fault! With the new Health care reform, insurance comapnies must allow its members preventive care and screenings with no cost sharing. So in order for them to still make their HUGE profits, they now only offer large deductible plans to their members and patients are now responsible for labs and imaging services that they previously wouldn't have. They are now getting bills for services that they have always received and never been billed. It's happening everywhere. We get calls all day long about the bills their receiving. The most popular one is this one about "preventive screening labs". I love it when the insurance company reps tell the patients, that we are coding incorrectly!

The rule has always been this: Screening tests are defined as done/ordered in the course of an annual physical examinatin or as part of a routine physical check-up, WITHOUT SIGNS, SYMPTOMS OR THE PRESENCE OF AN ILLNESS.

I actually have to explain this to the insurance company reps! I asked one of the large plans for written documentation on this, and she said to me, it's not up to them to tell us how to code!

Never a dull moment in healthcare billing and coding!

I agree to a point, and have tackled our local payers with regard to their "you've coded it wrong" message. That, I'm happy to report, has all but evaporated from our radar, and patients are beginning to understand the concept of compliance from our perspective. However, insurance companies are doing exactly what our government required (and our nation needs) .....paying 100% for preventive care. Up until ACA, preventive services weren't typically covered at all, except for a well-exam and an annual pap. Now they're virtually all paid at 100% provided you're symptom free...which is what preventive care is. There's the catch!! How many Americans can say they are healthy and symptom free? Not too darn many, and that is why they're ticked off at our billers when we deliver the message that they can't receive 'preventive care' because they're already symptomatic?
Americans hear "free health care" and think that they are entitled...even though they already have diseases and symptoms that we cannot possibly re-screen for. Some health plans have even gone so far as to document this in their coverage limitations, which is helpful only if you read your policy.

While it is impossible to prevent diseases you already have... some preventible diseases (hypertension, hyperlipidemia, diabetes, obesity) can be reversed with proper self-care. And by getting these numbers under control, Americans can reduce their overall healthcare expenditures. The ACA is finally forcing Americans to take a good hard look at their unhealthy selves, and attempting to make some changes to our overburdened system by rewarding the healthy instead of rewarding the sick like we've been doing. About time, I say. As a healthcare consumer and an employee with an employer-sponsored health plan, I'm a tad indignant that my premiums increase year after year, while I watch my co-workers continue to smoke, eat junk at their desks, and refuse to exercise. I sympathize....to a point. But let's place at least some of the blame where it belongs.

[genjer712]

I agree and disagree with a lot of the points made. First of all, I work for an insurance company and have for several years. I am almost offended by the comment" it is all the insurance companies fault". For the majority of the plans, preventive care is paid at 100%. But it is for truely "preventive care". If you already have diabetes, what are you preventing? We process claims based on how claims are received. We look at the pointers that are used for each lab/service billed. Working in customer service, we get calls all day long saying we processed the claims wrong. Our response, "we process the claims on how the claims are received". If the pointer used is for a medical DX, then "yes", we apply the lab/service to the appropriate level of benefits such as deductible/coinsurance. If it states "routine", we process at 100%. We offer to outreach to the provider to confirm if correct DX is used. Most of the time the response we get is "yes the patient was here for routine exam, however we discussed his underlying medical issues as well. Therefore, billed the medical DX". Patients do not understand this. They "assume" since they are going for their routine exam, it should all be covered in full.

On a personal note....my own doctor has a memo in each treating room that states if they discuss anything other than routine matters during the routine exam, they will also bill for a problem focused exam. Or they want you to schedule a separate exam to discuss the “other issues”. Again, patients are not advised of this when going in for their own routine exams.

Everyone is quick to point a finger at the insurance company that the plans offered to the companies are all high deductible plans. When in reality, the employers are choosing their own plans. It is cheaper for the employer to choose a high deductible health plan (HDHP) and put more of the cost on the employee. Insurance companies still have copay plans and HMO plans, but they are very costly to the employers. Employers cannot afford it. Therefore they lower their cost by choosing a HDHP and putting more of the cost on their employees.

This is just my 2 cents...hope no one takes offense!

Gena

[Pam Brooks]

Originally Posted by genjer712

I agree and disagree with a lot of the points made. First of all, I work for an insurance company and have for several years. I am almost offended by the comment" it is all the insurance companies fault". For the majority of the plans, preventive care is paid at 100%. But it is for truely "preventive care". If you already have diabetes, what are you preventing? We process claims based on how claims are received. We look at the pointers that are used for each lab/service billed. Working in customer service, we get calls all day long saying we processed the claims wrong. Our response, "we process the claims on how the claims are received". If the pointer used is for a medical DX, then "yes", we apply the lab/service to the appropriate level of benefits such as deductible/coinsurance. If it states "routine", we process at 100%. We offer to outreach to the provider to confirm if correct DX is used. Most of the time the response we get is "yes the patient was here for routine exam, however we discussed his underlying medical issues as well. Therefore, billed the medical DX". Patients do not understand this. They "assume" since they are going for their routine exam, it should all be covered in full.

On a personal note....my own doctor has a memo in each treating room that states if they discuss anything other than routine matters during the routine exam, they will also bill for a problem focused exam. Or they want you to schedule a separate exam to discuss the “other issues”. Again, patients are not advised of this when going in for their own routine exams.

Everyone is quick to point a finger at the insurance company that the plans offered to the companies are all high deductible plans. When in reality, the employers are choosing their own plans. It is cheaper for the employer to choose a high deductible health plan (HDHP) and put more of the cost on the employee. Insurance companies still have copay plans and HMO plans, but they are very costly to the employers. Employers cannot afford it. Therefore they lower their cost by choosing a HDHP and putting more of the cost on their employees.

This is just my 2 cents...hope no one takes offense!

Gena

Gena, none taken, and great post. What we hear from patients is that the insurance representatives are blatantly telling them that we coded these incorrectly. That's the part that's frustrating! If only all insurance company employees were as knowledgable as you! I've found it helpful to work directly with our provider representatives. Establishing good working relationships with these individuals makes coders' lives easier, and I'd encourage everyone to do the same.

Have a good weekend, all.