Many family physicians are coding correctly, only to be told to cease and desist. Some FPs are being threatened with exclusion from health plans for coding higher than other physicians. So the Academy is going to put health plans' feet to the fire.
Fifteen resolutions from chapters and heated testimony on health plan practices led the AAFP Congress of Delegates to take action against rejections of appropriate claims.
Coding Correctly But Denied Payment? Help Is Coming
By Jane Stoever • AAFP Assembly San Francisco
AMA should require health plans to follow CPT rules, says David Ellington, M.D. "We cannot be shrinking violets when it comes to advocacy."
Start gathering any spare kindling you've got by way of health plan refusals to pay you in accord with CPT provisions. Delegates voted for the Academy to set up a health plan clearinghouse where members can report such practices and build up a data bank. Then AAFP leaders will use the data in discussions with employers and health plan leaders, and you can track patterns from plan to plan.
Reference committee testimony this week focused on the failure to pay correctly for claims with a "-25" modifier -- instead of covering several services given at one visit, insurers bundle them together and pay less than CPT allows.
"It's like going to the grocery store to get bread, milk and butter and expecting the grocer to throw in a steak because you’re there," FP Steven Bruner, M.D., of Lawrence, Kan., told the reference committee. "If you 'bundle in' the steak without the grocer's permission, we would call that shoplifting. There was a day when we could afford to throw in those services without being compensated. But in light of Medicare and Medicaid cuts, those days are past."
Michigan AFP President Peter Scuccimarri, M.D., of Ann Arbor said he had seen two patients in the past two weeks with acute cellulitis of the lower left extremity. One needed hospitalization; one did not. "For the one not hospitalized, I'll get 'dinged' for the cost of care. But who do you think cost the health care system more?" asked Scuccimarri. "This is really common sense, but coding and reimbursement are anything but," as far as insurance companies are concerned.
It is not acceptable for health plans "to threaten to restrict, terminate or exclude a family physician from plan participation based on his or her coding pattern" if the physician provides medically necessary services and abides by CPT rules, the delegates decided.
Delegates also called on the Academy's AMA delegation to work within the AMA to ensure adherence to coding guidelines outlined in the CPT manual and CPT licensure contracts with insurance carriers.
"We cannot be shrinking violets when it comes to advocacy," said delegate David Ellington, M.D., of Lexington, Va. He suggested to the reference committee that when the AMA sells CPT codes to health plans, the AMA should require the plans to follow CPT rules.
"Insurance companies should have to adhere to the CPT code, but I don't think the AMA has a big enforcement stick," Colette Willins, M.D., of Westlake, Ohio, a member of AAFP's delegation to the AMA, told the reference committee.
Reference committee testimony this week focused on the failure to pay correctly for claims with a "-25" modifier -- instead of covering several services given at one visit, insurers bundle them together and pay less than CPT allows.
"It's like going to the grocery store to get bread, milk and butter and expecting the grocer to throw in a steak because you’re there," FP Steven Bruner, M.D., of Lawrence, Kan., told the reference committee. "If you 'bundle in' the steak without the grocer's permission, we would call that shoplifting. There was a day when we could afford to throw in those services without being compensated. But in light of Medicare and Medicaid cuts, those days are past."
Michigan AFP President Peter Scuccimarri, M.D., of Ann Arbor said he had seen two patients in the past two weeks with acute cellulitis of the lower left extremity. One needed hospitalization; one did not. "For the one not hospitalized, I'll get 'dinged' for the cost of care. But who do you think cost the health care system more?" asked Scuccimarri. "This is really common sense, but coding and reimbursement are anything but," as far as insurance companies are concerned.
It is not acceptable for health plans "to threaten to restrict, terminate or exclude a family physician from plan participation based on his or her coding pattern" if the physician provides medically necessary services and abides by CPT rules, the delegates decided.
Delegates also called on the Academy's AMA delegation to work within the AMA to ensure adherence to coding guidelines outlined in the CPT manual and CPT licensure contracts with insurance carriers.
"We cannot be shrinking violets when it comes to advocacy," said delegate David Ellington, M.D., of Lexington, Va. He suggested to the reference committee that when the AMA sells CPT codes to health plans, the AMA should require the plans to follow CPT rules.
"Insurance companies should have to adhere to the CPT code, but I don't think the AMA has a big enforcement stick," Colette Willins, M.D., of Westlake, Ohio, a member of AAFP's delegation to the AMA, told the reference committee.
