Upcoding

[somarco]

The doctor noticed a little splinter in the child's palm. The doctor grabbed a pair of forceps — aka tweezers — and pulled out the splinter in "a second," Lai said. That brief tug was transformed into a surgical billing code: Current Procedural Terminology (CPT) code 10120, "incision and removal of a foreign body, subcutaneous" — at a cost of $414.

When Helene Schilders of Seattle went to her dermatologist for her annual skin check this year, she mentioned her clothing was irritating a skin tag she had. The doctor froze the tag with liquid nitrogen. "It was squirt, squirt. That's it," Schilders told me. She was "floored" by an explanation of benefits that said the simple treatment had been billed as $469 for surgery.

Removing a Splinter? Treating a Wart? If a Doctor Does It, It Can Be Billed as Surgery - KFF Health News

Minor interventions are increasingly being rebranded and billed as surgery, for profit. This means a neurologist spending 40 minutes with a patient to tease out a diagnosis can be paid less for that time than a dermatologist spending a few seconds squirting a dollop of liquid nitrogen onto the skin.

kffhealthnews.org

 

[annon123]

Upcoding for the doctor part of the bill goes on in a local non-profit hospital's ER where they are subcontracted staffing of that to a for profit company. In that particular case the ER staff have a "mandate that every patient has at least $1200 in billable charges". If they can't get that then they lie in the notes about time spent, etc. Harder to prove unless what they are lying about involves charges on the hospital side of things that aren't there in the bill (for example claiming someone had an IV when they didn't - where is the facility IV charge for supplies?).

Upcoding also happens when doctors claim they spend X minutes overall including time with the patient (as part of that coding is time spent), time prior to their visit preparing, time post visit, etc. Now some of that time is legit of course but I am sure if someone linked a provider with all patients they saw in a day with amount of time they claim they spent total, it would result, for some, in far more than a 24 hour a day. Claim you spent 45 min to an hour total each patient and you see 3-4 patients an hour and see patients 7-8 hours a day. Oops. Math, just like gravity, works all the time not just when you want it to.

 

[Limozine]

This is a big reason that doctors and physicians groups are such big fans of original Medicare, and why they hate Medicare Advantage so much. With OM, the member has usually already paid for a supplement and has no additional "skin" in the game, so doctors are free to bill it however they see fit. The government is unlikely to question it and no one will ever complain. On the other hand, if I'm the member and I have an MAPD, the difference between a routine specialist visit vs outpatient surgery is easily $25 vs $395, out of my pocket. As the patient, I want to know how the procedure will be coded. Four years ago my father had one facial skin cancer removed - $350 copay. This past year he had three skin cancers removed - exact same procedure (Mohs surgery) on three different dates, but this time at a different clinic. This clinic charged $30 per procedure.

 

[somarco]

subcontracted staffing of that to a for profit company.

Many folks don't realize the number of folks in the ER, radiology, lab, etc are not staff employees but contract help.

Years ago I had a client who was a "traveling" ER doc that covered 4 states. She usually worked for a week in one hospital then moved to another one, sometimes in a different state, and worked there for a week or so.

When explaining Part A charges I tell clients A covers charges incurred as an inpatient AND billed by the hospital. Patients are often surprised at the number of (Part B) bills received after the fact which can add quite a bit to the total.

Rachel spent 4 days in the hospital for a broken hip. We got Part B bills for the ER, radiology, surgeon, assistant surgeon, anesthetist and for a "hospitalist". The Part B charges were almost equal to the A charges.

With OM, the member has usually already paid for a supplement and has no additional "skin" in the game, so doctors are free to bill it however they see fit.

Well, except for the medical necessity part and matching the ICD codes with CPT.

OM is not an all you can eat buffet like so many agents say.

Upcoding is not the exclusive domain for OM providers.

The linked article does not mention the type of coverage, managed care or indemnity, but I don't think there are any pediatric patients on Medicare.