Pediatric Coding Alert

When a pediatrician sees a newborn in the hospital, he or she may well not know whether the child has health insurance coverage. If it turns out that there is no insurance, what should your billing department do? And considering that many of these patients may be eligible for or even enrolled in Medicaid, how should you navigate your way through the publicor, in some cases privatesystem?

The Medicaid Dilemma

This is an interesting question, says Cece Fontaine, RN, office manager for L. Fiatoa, MD, a pediatric practice in Honolulu, HI. Were right outside a public housing project, so 98 percent of our patients are on welfare.

Fontaines problem with this is typical of many pediatric practices with a large proportion of Medicaid patients. The pediatrician receives a capitated payment each month for each Medicaid patient, but the parents may not always go to that pediatrician. The mother may not even give birth in a hospital where that pediatrician has privileges. So, the pediatrician who ends up treating the baby, but is not the assigned provider, may need to ask the assigned provider to refer the patient to him or her. Otherwise, the capitated payment will go to the wrong pediatrician.

Many of the patients in Fontaines practice are on Medicaid, but in Hawaii, as in many states, Medicaid patients are being assigned to commercial plans. That means that they can only go to their chosen (or assigned) pediatrician. A lot of us are capitated, says Fontaine, referring to physicians in Hawaii. The patient presents the practice with a card, but it has another pediatricians name on it. If we end up taking care of someone elses patient, we might end up eating the costs.

There is a way to avoid this problem. It takes a little bit of time, but its worth itespecially when you think about how many visits and shots you will be giving during a childs first year of life. Heres what you can do.

The Retroactive Referral

You can try to initiate a referral from the other doctor, says Fontaine. Contact the office of the other pediatrician, and say that you have been seeing this patient. You should do this diplomatically, of course; what you are doing is asking your colleague to hand over his capitation to youincluding the fees from the months during which you have already cared for the baby. But, after all, you are the one who is earning the payments.

Tip: If hospital visits are carved out of the capitation, as they are in Hawaiis Medicaid plans, at least you will be reimbursed for the newborn exam and any care you provided in the hospital.

If [the other practice] is willing and nice, they will write a letter to the insurance company saying, `I have never seen this patient who was assigned to me, and the other pediatrician has been treating the child with the understanding that this patient would be assigned to him, says Fontaine.

Then, you should write to the insurance company and say that you have treated the patient and expected to be assigned as their pediatrician, says Fontaine.

Tip: The pediatrician who is treating the patient cant contact the managed Medicaid company and recommend a change in physicians. But, if the other pediatrician sends in the referral letter, there is usually not a problem, says Fontaine.

After the reassignment takes place, the treating pediatrician can file the claims from the first visits, asking the company to honor the retroactive referral, says Fontaine. But, there is extra work involved for the billing department. We have to get the hospital records and resubmit all the claims, she adds. But if we do this, we can recoup.

Tip: Another way to handle this is through contract negotiation with the managed care company. The pediatrician should establish a contract that allows for reverse capitation when patients are assigned to the wrong pediatrician.

Finally, Fontaine notes that sometimes there is no choice but to write off or discount charges to uninsured patients. Is discounting your services fraud? What can I say, Fontaine says, sighing. You cant squeeze blood from a turnip.

Tip: If you want to find out if a patient is eligible for Medicaid, call your state Medicaid office. Most are organized enough that they can tell you right away. Also, if the parents make too much money to be eligible, but are still too poor to pay for health care, the state may help out with the costs.

Parent Education

What if the child isnt covered by any insurance, including Medicaid, and the parents say they are going to pay out of pocket for all of the costs? You should make sure that the parents know what these costs will be up front, says Susan Johnson, CMA, office manager for Corvallis Childrens Clinic, a solo practice in Corvallis, OR.

If the parents request a pediatrician at the time of the birth, and they dont have insurance, and the physician becomes the childs physician, there are certain steps that need to be followed, says Johnson. When the baby is born, the parent gets a sheet of paper listing what well-child examinations must take place during the first year.

Tip: All parents, regardless of their insurance status, get this list. It helps them plan for the busy year ahead.

There are no costs printed on the sheet, says Johnson. But, if the parents have no insurance, then I feel theres an obligation on my end to inform them of what these costs are, she says. She does so herself, when the parent brings the baby in for his or her first visit, usually at two weeks. Johnson tells the parents about all of the costs involved, including office visits, shots, and lab tests. And she also tells the parents what the fee range is for sick visits. We cant predict how often the baby will be sick, she says.

Also, at this first visit, Johnson works out a payment plan with self-pay parents. If the parent says he or she will pay at each visit, thats fine. Otherwise, Johnson can work out a monthly payment that takes into account all of the well-child exams. (Sick visits, of course, would be added on.)

Each time the self-pay parent comes in with the child, the payment plan is verified, says Johnson. Parents need to be reminded as well of their future obligations in terms of both sick and well visits.

Even for parents with insurance, Johnson likes to make sure they understand how the deductibles and co-pays work. I say it behooves them as a mom or dad to know how their insurance works, she explains. A lot of people dont understand it, and expect their doctors to walk them through it.

Correct coding is still essential, even if parents are self-pay. You need this information for your own records, because keeping track of procedures will help you keep track of productivity.

Finally, Johnson believes its important for the office manager to spend some time talking with self-pay parents. I personally talk to each of these parents, she reports. That face-to-face helps down the road, and a little bit of tension is relieved as well.

Far too many office managers, staff, and pediatricians dislike discussing payment issues. As a result, in many cases nothing is done until the account is overdue and then the parent is no longer grateful to you for healing their child. It is essential to discuss these issues up front.

So, if a newborn enters your practice without insurance coverage, dont despair, but dont give away your services.