"Do the right thing," is the message AAFP is sending to 44 health insurance plans in response to family physicians' frustration with health plans that cut corners with CPT coding by inappropriately bundling a patient's preventive care visit with a problem-oriented evaluation and management service when both services occur on the same day.
Academy Calls on Health Plans to Quit Bundling Certain CPT Codes
By News Staff
12/1/2005
In a Nov. 9 letter, AAFP Board Chair Mary Frank, M.D., of Mill Valley, Calif., asked insurers to use appropriate existing CPT codes and the modifier "-25" to ensure that physicians receive proper payment for services provided.
One problem FPs are encountering is that many private payers are using software that automatically bundles the services when they are performed on the same date, noted Frank. Some payers fear that without such precautions, physicians may try to take financial advantage by always finding a medical problem during a routine physical, an annual gynecological exam or a preventive visit, she added.
"We believe it is false to assume that physicians are motivated by reimbursement when treating a patient's condition that is unrelated and separately identifiable to a preventive visit," said Frank. In fact, many physicians don't want to inconvenience patients by asking them to schedule a second appointment to address a medical problem, she said.
That additional visit also adds to fragmentation of care, more time off work for the patient and an additional administrative expense for the physician.
Frank said under the current system, many physicians end up writing off the cost of addressing the medical problem during the preventive visit. That's because physicians usually are prohibited by health plan contracts from billing the patient separately for the bundled services.
"From our perspective, this is an unfair business practice amounting to nothing more than your members (patients) receiving free care," said Frank. "Both appropriately documented and billed services deserve to be paid either directly by the patient and/or health plan."
One problem FPs are encountering is that many private payers are using software that automatically bundles the services when they are performed on the same date, noted Frank. Some payers fear that without such precautions, physicians may try to take financial advantage by always finding a medical problem during a routine physical, an annual gynecological exam or a preventive visit, she added.
"We believe it is false to assume that physicians are motivated by reimbursement when treating a patient's condition that is unrelated and separately identifiable to a preventive visit," said Frank. In fact, many physicians don't want to inconvenience patients by asking them to schedule a second appointment to address a medical problem, she said.
That additional visit also adds to fragmentation of care, more time off work for the patient and an additional administrative expense for the physician.
Frank said under the current system, many physicians end up writing off the cost of addressing the medical problem during the preventive visit. That's because physicians usually are prohibited by health plan contracts from billing the patient separately for the bundled services.
"From our perspective, this is an unfair business practice amounting to nothing more than your members (patients) receiving free care," said Frank. "Both appropriately documented and billed services deserve to be paid either directly by the patient and/or health plan."
Make Your Voice Heard
Would you like to contact payers about this issue? The Academy has created a letter template (MS Word file: 4 pages / 35 KB. More about downloading files.) to help members expedite a personal appeal to insurance companies that continue to practice inappropriate bundling of services.
Frank pointed out that Aetna has said it would change its payment policy in February to allow payment for preventive and problem-oriented services on the same date of service. She called on other insurance companies -- including many BlueCross BlueShield companies, CIGNA, Humana Inc., UnitedHealth Group and WellPoint Inc. -- to do the same.
