Quote:
Originally Posted by blueash
I will do my best to explain, my understanding, of how this works. Medicare (CMS) gives private carriers (UHC, Humana etc) an opportunity to cover patients who qualify for Medicare. Those carriers are paid a fixed amount per covered life to cover all costs, physicians, hospital, pharmacy, lab, etc.
The only adjustment comes if it turns out that the patients who enroll are sicker than the average Medicare aged patient. If that is the case, then the amount paid is bumped up per patient. That difference goes to the insurance company who then uses the same bumped up factor to pay the providers.
So if by listing diagnoses where no active intervention or ongoing management exists you get your patient looking sicker (lots more diseases and disorders) the provider ends up making extra because their monthly payment is increased for each patient in the plan.
Now this assumes that TVH is paid a capitated per patient amount from UHC. Alternatively TVH could be providing fee for service and billing UHC for each encounter. I have always believed, but DO NOT KNOW, that this is not how it works. In the case of fee for service then the only way to increase payment is to bill for services at a higher level or complexity. I can tell you from my own EOBs that I see no evidence of that being the case. A routine exam is being billed with the correct codes, and illness visits are also being correctly billed as to complexity. I have seen no charges for services not done.
Lastly, entirely IMO, I do not believe any of this was fraud. Rather it is a quirk in the system where the doctor wants everything in the chart for completeness but that completeness makes the patient look sicker as most offices don't bother computer entering everything.
What is needed is a way to enter a concern, but to be able to note that it is not requiring management. There are so many of these that every patient has. A patch of dry skin, occasional headaches that have been for years, mild spring allergies, intermittent constipation. These kinds of things are true, real, and should be noted. But if there is not ongoing management, just living with it, the entry in the record becomes a problem as CMS cannot differentiate actively managed vs not managed.
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Fact check: TRUE
However, one can go into their electronic medical records and make adjustments, if they are using EPIC.
When I questioned the doctor about the forever list, he said its there for reference of past medical history issues. . "OK", until you get to Medicare.
However, I am not yet on Medicare, and will convert at the end of this year. . when I have to then have a "Medicare" physical. .
One last point about physician services codes and billing codes:
In large systems, such as EPIC in large hospital systems, there is automation for many of the mundane and commonly used service codes to billing codes.
However, there is constant reviews and auditing methods to insure proper compliance. In physician only medical offices, which may be using small system electronic medical records, the process may be more manual than big hospital systems. . BUT they have a choice of partnering with a major hospital system and using their system as a separate instance. . .
My eye doctors' office uses the Mass general or brighams womens EPIC system, and their hospital payment system. . and am having a billing issue with them right now.
but we learn alot here on TOTV, with all the previous work experiences who have actual knowledge of the issue du jour