CDHPs are Much Worse THan You Think
Matthew Holt over at The Health Care Blog posted a pretty interesting article over the weekend from the Miami Herald about one of the many glitches yet to be uncovered in using HDHPs.
It seems that the young lady had an earache, went to an urgent care center (no PCP?) and got billed for $350. Part if the problem was that the Urgent Care Center was out-of-network, something that it was her responsibility to know, a fact the Center didn’t bother to tell her when she presented her health card notwithstanding. (IMHO, at least part of the reason OON providers don’t tell the patient whether they are in or out-of network is that if they are OON, they often will get paid more by a managed care plan The patient, will of course have a larger co-insurance, too.) In this case, a HDHP takes advantage of the same abusive billing practice.
But this problem is bigger. The UCC billed CPT 99245, a level 5 consultation. A consultation is different from a visit in that it requires a specific request by another provider, which, if the story is accurate didn’t happen here. So that makes it an “initial outpatient visit” coded instead somewhere between 99201 and 99205.
The second problem is the level 5 code. If we assume the level of care (5) is the same, an example of a 99205 visit could be (as close to the specialty of straight internal medicine as I could get): “Initial visit for a 42 year old male on hypertensive medication, newly arrived to the area, with diastolic blood pressure of 100, history of recurrent calculi, episodic headaches, intermittent chest pain and orthopnea (trouble breathing unless upright).” Any of this sound like the severity of an earache to you?
A third problem is that she didn’t se a doctor; she saw a nurse practitioner. That drops the code even lower to perhaps 99211, although that is usually used for an established patient.
The bottom line difference in cost? Between $200 and $300.
So unless the HDHP comes with a current CPT (professional edition), a copy of the National Correct Coding Initiative (updated quarterly; also available on line), and transparent information about when these regulations are applicable and when they are not, and perhaps an independent call center for people who can’t figure it all out, HDHPs will continue to be a deeply flawed and bordering fraudulent product.
IMHO, of course.
Crossposted at http://www.signalhealth.com
It seems that the young lady had an earache, went to an urgent care center (no PCP?) and got billed for $350. Part if the problem was that the Urgent Care Center was out-of-network, something that it was her responsibility to know, a fact the Center didn’t bother to tell her when she presented her health card notwithstanding. (IMHO, at least part of the reason OON providers don’t tell the patient whether they are in or out-of network is that if they are OON, they often will get paid more by a managed care plan The patient, will of course have a larger co-insurance, too.) In this case, a HDHP takes advantage of the same abusive billing practice.
But this problem is bigger. The UCC billed CPT 99245, a level 5 consultation. A consultation is different from a visit in that it requires a specific request by another provider, which, if the story is accurate didn’t happen here. So that makes it an “initial outpatient visit” coded instead somewhere between 99201 and 99205.
The second problem is the level 5 code. If we assume the level of care (5) is the same, an example of a 99205 visit could be (as close to the specialty of straight internal medicine as I could get): “Initial visit for a 42 year old male on hypertensive medication, newly arrived to the area, with diastolic blood pressure of 100, history of recurrent calculi, episodic headaches, intermittent chest pain and orthopnea (trouble breathing unless upright).” Any of this sound like the severity of an earache to you?
A third problem is that she didn’t se a doctor; she saw a nurse practitioner. That drops the code even lower to perhaps 99211, although that is usually used for an established patient.
The bottom line difference in cost? Between $200 and $300.
So unless the HDHP comes with a current CPT (professional edition), a copy of the National Correct Coding Initiative (updated quarterly; also available on line), and transparent information about when these regulations are applicable and when they are not, and perhaps an independent call center for people who can’t figure it all out, HDHPs will continue to be a deeply flawed and bordering fraudulent product.
IMHO, of course.
Crossposted at http://www.signalhealth.com
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