Paul Durr said a patient recently came to his office in Vienna for a well-woman exam. During the visit, she remarked, "By the way, my foot hurts," he said. The internist determined she had plantar fasciitis and gave her an injection to relieve the inflammation.
When he asked a CareFirst official how to submit claims for the exam and the injection, Durr said, he was told the insurer would not pay for both services -- because, as Durr quoted the official, "a patient cannot have an office visit and a procedure on the same day."
Durr said he's not upset at the prospect of losing the money -- each of the claims would net him about $60, he said -- "it's just the idea of it" that he can't fathom.
Asked for comment, CareFirst did not provide a spokesman to explain its stance on such claims.
As senior editor at Physicians Practice magazine, Pamela Moore researches problems that doctors encounter with insurers. She said Durr should get paid for both claims "because he's provided a very specific service" beyond the scheduled exam. "He's also provided the supplies, the actual stuff that's in the needle."
"You would think they would want to provide this service to their patients," she said. "What happens, though, is that a lot of payers [refuse] and then it becomes big debate. . . . That's why a lot of providers won't do it: either they don't know that they can or they know that the payer's going to turn it down and it's going to be a big hassle."
Durr's experience "is probably one of the most common symptoms that we see of a sick health system," said William F. Jessee, president of the Medical Group Management Association (MGMA). "It's one of the things that drives physicians crazy about health care and the complexity of the billing system." More than 200,000 doctors practice in groups that are members of MGMA, which is based in Englewood, Colo.
"A lot of the payers . . . basically take the position that it doesn't take you any more time to do the other procedure, therefore we shouldn't pay you any more, even though the coding convention that everybody has agreed to contractually says that you should be paid for the second procedure in the same visit."
Jessee said, "I have had numerous members who have told me, 'I have asked the health plans how do I code this according to your rules to make sure that it's paid,' and they can't get that information in advance from the plans. So it's little bit like: 'We have rules, but we're not going to tell you what they are. . . . But if you don't play by them, we won't pay you.' "
Jessee said coding disputes are one factor in a nationwide class-action lawsuit against several insurers. Cigna and Aetna have settled with the plaintiff physicians by, among other things, promising to ease rules for multiple same-day claims.
-- Tom Graham
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