American College of Physicians: Internal Medicine — Doctors for Adults ®

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Taking a tough stand on nonbillable care

Some physicians have resorted to charging patients for services they once gave away

From the February ACP-ASIM Observer, copyright 2003 by the American College of Physicians-American Society of Internal Medicine.

By Phyllis Maguire

In tough times, physicians give billing practices new scrutiny
Is patient e-mail the next big nonbillable?
Taking an attorney's approach to billable time
Tips to bill Medicare patients for preventive care

Internist Joel S. Levine, FACP, wonders what would happen if you told a hospitalized patient—who would routinely pay a plumber for travel time to fix a clogged drain—that you planned to bill him for the time you spent driving to the hospital to see him.

"He'd look at you like you were nuts," said Dr. Levine, a College Regent and dean for clinical affairs at the University of Colorado School of Medicine. "Patients simply have no sense of the value of your time."

While Dr. Levine's scenario describes many patients' attitudes, it also gets at physicians' growing aggravation over the hot-button issue of "nonbillable care."

Physicians everywhere say they're tired of providing services they can't bill for that eat up time and expose them to liability. They are also fed up with providing medical care that is not covered by insurers—and are no longer willing to absorb those costs if patients refuse to pay.

Some physicians are taking a hard line and creating new policies that shift some or all of the costs of nonbillable services onto patients. Others say they are spending more time trying to convince patients to pay out-of-pocket for services insurers don't cover.

Many of the new policies, like discouraging phone consults in favor of office visits, can improve patient care. But for many physicians, the driving force behind their efforts has as much to do with boosting revenue as enhancing care.

"Any time physicians extend liability or incur expense, they should bill for it," said Joseph A. Leming, MD, a primary care physician in Virginia. "Either the time is right for patients to bear more costs of services, or it's time to go out of business."

Policies, not apologies

Because they feel they're being bombarded by nonbillable services, a growing number of doctors are asking patients to pony up their own money to cover a service, or trying to convert the service to a billable office visit. Here's a look at some of the nonbillable services physicians are tackling:

  • Copies and forms. Many of the physicians interviewed for this article said they make no apologies about charging patients for copying records and filling out forms.

    Dr. Leming, a family physician and managing partner with Prime Care Family Practice in Colonial Heights, Va., for instance, said his practice had no idea how many forms the group's four physicians and four nurse-practitioners were filling out until they started routing them all to one administrator. "We were astonished at the volume," he said. It was roughly seven times what anyone expected.

    As a result, the practice now charges patients for filling out all forms and applications. A simple disability form that needs a physician's signature and a copy of the office note costs patients $15, while patients can expect to pay up to $250 if their insurance companies require physicians to dictate a detailed letter describing the patient's disability.

    Patients who want their physician to complete assisted-living application forms need to come to the office and pay for a complete physical. And the practice flat out refuses to complete some forms, such as lengthy drug assistance program forms from individual drug companies. Instead, Prime Care refers patients needing that type of assistance to patient-administered programs like Together-Rx.

    To avoid generating bills and incurring even higher costs, the practice makes patients pay for forms up front. They also have to pay off any outstanding balances before they can get the completed form.

    Some practices that can generate forms with electronic medical record (EMR) software now charge a premium if patients don't use them. In Cincinnati, for instance, Queen City Physicians, a primary care practice with 30-plus physicians and seven sites, adopted a two-tier charge approach for family and medical leave forms.

    "If patients allow us to complete forms generated by our EMR, we charge $25," said Pamela Coyle-Toerner, the practice's president and chief operating officer. "If we have to fill out the provider's or company's form, we charge $40."

  • Phone calls and no-shows. Phone calls are another service that are not separately billable and eat up physician time. Medicare rules state that payment for phone time is included in its payment for the face-to-face encounter to which the call pertains. Medicare considers phone time as typical post-encounter follow-up.

    However, there are ways for physicians to get paid for substantial phone time. To make sure he is paid for the time he spends on patient phone calls, for instance, Allen M. Dennison, ACP-ASIM Member, general internist with Medical Associates of Rhode Island in Barrington, R.I., said he typically upcodes the patient's next office visit.

    If he spends 15 minutes on the phone with patients before telling them to come in, "I document that I've done extra work and charge a 99214 instead of a 99213," he said.

    Physicians can also charge patients directly for phone calls associated with a new problem not related to a face-to-face visit. For instance, for patients who winter in Florida but insist on getting medical care over the phone—a practice Dr. Dennison strongly discourages—he directly bills them $2 a minute.

    Virginia's Prime Care doesn't charge patients for phone calls, Dr. Leming said, but its physicians try to get patients to come for an office visit, including those who call after-hours. Appointment clerks contact all after-hours callers the next day to ask if they need a follow-up visit. Patients appreciate the callback, physicians have a chance to look into serious or chronic symptoms and many calls become billable visits.

    And next month, Prime Care plans to implement a $15 to $20 charge for no-shows who don't cancel appointments at least four hours in advance. While the practice is already standard operating procedure for dentists and psychologists, it is new for most physicians.

  • Prescription refills. Some practices have already begun charging patients for prescription refills. Jack Keller, vice president of medical group administration for Christus Primary CareNet, a managed services organization in San Antonio, said that the network's psychiatric patients must come into the office every three months to get refills.

    If those patients fail to schedule an appointment and call for a refill instead, they now have to pay $10 to pick up a prescription for a one-week supply of their medication. (They can't get another refill without an appointment.) The charge has been so effective in motivating patients to schedule follow-up visits that one practice was able to take a staff member off refill management duty.

    To date, Mr. Keller said the network's internists and family physicians have balked at extending similar requirements to their patients, afraid that many would simply stop taking medications if they couldn't phone in refill requests. "But they're talking about it," he added.

  • Drug switches. While Virginia's Prime Care doesn't charge patients for phoned-in refills, it does take a tough stand against another growing medication hassle: pharmacists wanting to replace a brand drug with a generic, or pharmacy benefit management companies (PBMs) wanting to switch a patient to a formulary-approved drug.

    To honor those requests, staff would have to pull charts and physicians would have to consider how the proposed switch might affect patient care. Instead, the physicians now refuse to approve drug switches requested by pharmacies or PBMs unless patients come in to the office.

  • Drug reps and samples. Queen City Physicians in Cincinnati is taking a radical approach to nonbillable time with drug detailers: charging them for physician face time. The group signs consulting agreements with drug companies, whose representatives pay $65 for 10 minutes with a physician. The resulting revenue helps offset the costs of Queen City's $750,000 EMR.

    So far, only smaller drug makers have signed on for the service. Larger companies still drop off samples, said Queen City president Ms. Coyle-Toerner, but they don't get to see physicians.

    Prime Care's physicians have also stopped seeing drug representatives, and the group may take a hard line on samples that drug detailers leave at the front desk. Administrator William Webb said he is drafting a new sample policy for the practice.

    "We need to figure out when we give out samples and to whom," he said. "Patients come in all the time for a month's supply of samples without scheduling a visit or paying a $10 co-pay."

Persuading patients to pay

Many physicians now trying to limit nonbillable care say they can no longer afford to serve as a safety net for a broken health care system. "We're becoming an indigent pharmacy," Dr. Leming said, speaking of samples. "I'm opposed to my practice losing productivity to solve a national problem."

Others say they feel no discomfort telling patients the free ride is over. "It doesn't bother me to ask for money at all," said Rhode Island's Dr. Dennison. "I work for a small fraction of what a cardiac surgeon makes, so I have to be scrappy."

But some physicians are afraid that charging for nonbillable care will hurt market share or anger patients. Others admit they find it hard to discuss charges with patients—conversations that make some physicians "feel like a tradesman," said College Regent Dr. Levine.

While some physicians say that policies on form-filling charges can be explained at the front desk, that approach may not work when talking about medical services insurers don't cover.

Trying to persuade patients to pay for tests or medications not reimbursed by an insurer—or to sign an advance beneficiary notice (ABN), agreeing to pay out-of-pocket for services Medicare may not cover—is probably best handled by the physician.

"If I want my 70-year-old patient to get her cholesterol checked and Medicare won't cover it, I'm the only one who can persuade her," said Yul D. Ejnes, FACP, a general internist in Cranston, R.I., and Governor for the College's Rhode Island Chapter.

Dr. Ejnes said that many factors work against physicians talking with patients about paying for noncovered treatments or medications. Two big obstacles are time and patient expectations.

"Many patients think that everything they need is covered—and if it isn't covered, they don't need it," Dr Ejnes said. "For many patients, insurance is a blank check or a bottomless cup of coffee."

Physicians contribute to that problem, he added, when "we stretch and dig to find a diagnosis that covers a test, short of committing fraud. The word on the street is, 'If a doctor really wants a test done, he'll find a way to get it paid for.'"

When telling patients they need to pay for noncovered benefits, some physicians say they feel they're crossing the line from patient advocate to adversary. But Dr. Ejnes said he has come to view educating patients about their financial responsibilities as part of his advocate's role.

"We have to use these opportunities to bring patients face to face with financial realities," he said. "Politicians won't be bothered about this until the public is, and the public won't be bothered if we keep insulating them."

The new economics

For some physicians, the new economics of medicine have already stopped them from shielding patients from medical costs. Arnold Wax, FACP, Governor for the College's Nevada Chapter and a partner in a Las Vegas oncology practice, for instance, said that patients' commitment to paying for noncovered services comes up all the time with cancer drugs.

Medicare will definitely cover only those drugs the FDA has approved to treat a particular type of cancer. The program may deny payment for drugs that have shown good off-label results with other cancers.

Patients often exhaust proven treatments and are eager to try off-label ones. But if they don't sign an ABN and Medicare denies payment, Dr. Wax said his oncology practice "eats the cost." The price for three months of cancer treatments can run as high as $27,000.

That kind of price tag has led to heated discussions among the group's physicians—and a new policy. "Now, if a physician doesn't get the payment approved or an advance beneficiary notice signed," Dr. Wax said, "the drug costs come out of that physician's pocket."

Patients who refuse to sign have left the practice, angry that the group won't cover their drugs. But termination is really the only option, Dr. Wax said, particularly as the government proposes another cut in Medicare cancer drug reimbursements.

"If you don't sign the waiver, you won't get treated, and we will move to terminate your care," he said.

Even physicians who aren't at risk for medications or procedures are taking a hard line when it comes to noncovered services. Rhode Island's Dr. Dennison, for example, said he understands that patients sometimes balk at tests that may carry some physical risk, regardless of the cost. But if a patient who can afford services refuses to pay for basic preventive measures like physicals, Dr. Dennison said it's time to consider "firing" that patient.

"I tell them, 'You're not getting comprehensive care from me,' " he said. " 'Why don't you find a doctor who will approach this from a more economical point of view, or switch plans to an HMO that will cover the physical?'"

A growing number of physicians are now pushing to charge patients over and above Medicare's dwindling reimbursements. At its fall 2002 meeting, for instance, the Board of Governors passed a resolution to allow physicians to set fees and bill patients any overages not covered by Medicare.

In December, the AMA's House of Delegates passed a similar resolution endorsing the idea of balanced Medicare billing. Although both resolutions "reflect doctors' deep frustration," said College Regent William E. Golden, FACP, the College's representative to the AMA, they have little chance of being passed by Congress in the current political climate.

Nevertheless, physicians continue to look for ways to educate patients about the value of their time. For instance, Brian W. Kennedy, FACP, a general internist with a large multispecialty group in Milwaukee, once belonged to a smaller practice. He used to include this notation on patients' monthly statements when they phoned with late-night calls: "Telephone consultation: No charge."

"Patients might complain about the bill, but they tend not to remember that they had called about prescription refills or a sore throat," Dr. Kennedy said. "The message was that their care doesn't end when they leave the office."

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In tough times, physicians give billing practices new scrutiny

As physicians try to decide how—or if—to charge patients for nonbillable care, many are taking a much more aggressive approach to coding and billing for patient care.

More and more practices are hiring in-house coding staff to help physicians make the most of billable charges. And practices that have invested in electronic medical records find that charge capture is one of the systems' biggest pluses.

"We've seen marked improvement in our physicians' comfort level with coding and the ability to charge appropriately," said Pamela Coyle-Toerner, president of Queen City Physicians in Cincinnati, Ohio, a seven-site group that uses an electronic medical record system. "Some have seen their level of documented billing improve as much as 25%."

Physicians are also thinking much more carefully about whether the tests they want to order are covered.

"We used to do CBCs all the time without even thinking about them," said Harrison L. Robinson, ACP-ASIM Member, a general internist at Dean Medical Center in Madison, Wis. "Suddenly, you realize there isn't anything in the note that justifies doing a CBC from Medicare's point of view and you can't bill the patient for it."

While the problem was "fairly big" a year ago, Dr. Robinson said, the practice's physicians have become more careful about ordering tests.

Eric G. Tangalos, FACP, chair of community internal medicine at the Mayo Clinic in Rochester, Minn., said he now pays much more attention to nonbillables that should be billed charges. Every month, he discusses with individual physicians their documentation for ordering procedures like abdominal CT scans.

"Insurers deny payment because physicians list 'history of cancer' as their diagnosis instead of adding the 'abdominal pain' the patient presented with," Dr. Tangalos said. "We encourage physicians to use as many descriptive terms and diagnoses as possible and to get into the mindset of someone who has to pay the bill."

And as Medicare cuts physician reimbursements even further, some doctors may start billing for charges they didn't use to capture. Las Vegas oncologist Arnold Wax, FACP, Governor for the College's Nevada Chapter, for instance, said he routinely reviews lab work and makes chart notations for patients who come in between chemotherapy treatments—without billing Medicare for that management.

"But I'm allowed to charge a minimal visit," Dr. Wax said. "I may just start charging a 99211 every time they come through the door."

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Is patient e-mail the next big nonbillable?

As some physicians start charging patients for services like filling out forms, many are concerned about what may become the next big nonbillable: patient e-mail.

Patients like the convenience of e-mailing physicians, and many doctors think e-mail could play an important role in disease management or routine patient care. But along with major concerns about confidentiality and liability, physicians are loath to offer one more free service.

Late last year, Blue Shield of California became the largest insurer to reimburse physicians ($20) for online consults with established patients. And Medem is a service that encrypts e-mail exchanges between patients, who pay by credit card, and physician subscribers, who receive a monthly check from Medem. Most insurers, however, have no mechanism in place to pay for online time with patients.

At its January meeting, the Board of Regents considered a recommendation to lobby for Medicare reimbursement of e-mail consults. If Medicare made e-mail a covered benefit, said the College's regulatory analyst Mark Gorden, more private insurers would follow suit.

While the Regents are still reviewing the recommendation, College Regent Joel S. Levine, FACP, said there are arguments against lobbying to make e-mail a covered benefit. "Whatever Medicare would pay for e-mail, it wouldn't be much," he explained. "It might be better if e-mail was declared a noncovered benefit so we could bill patients directly."

For Dr. Levine, the prospect of billing patients for e-mail access raises the possibility of adapting some aspects of "boutique medicine," an emerging type of practice in which a small number of well-heeled patients pay physicians for unfettered access and services. (For more information, see "Fed up, some doctors turn to 'boutique medicine,'" in the October 2001 ACP-ASIM Observer.) While Dr. Levine doesn't subscribe to the boutique philosophy-saying it would damage patient access if adopted on a large scale—he might support modifying the concept to offer some boutique services.

"Patients who want more time or more than basic service could pay for it," Dr. Levine said. "Patients who want e-mail consults would pay extra for them, while those who don't want them wouldn't pay."

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Taking an attorney's approach to billable time

Administrators say there is one group that recognizes the value of physicians' time: attorneys. The profession that perfected the art of the billable hour is willing to pay physicians for theirs.

Jack Keller, vice president of medical group administration for Christus Primary CareNet, a managed services organization in San Antonio, said that internists in groups his organization manages now charge for depositions and legal consultations. The service is typically requested by attorneys representing patients or insurance companies involved in claims over auto accidents, occupational injuries or disability.

"We charge attorneys $350 for the first hour and $250 for the hour after that, with a one-hour minimum," Mr. Keller said. Physicians' travel time to and from attorneys' offices is included in those fees, which have to be paid in advance.

Hourly fees for subspecialists such as pediatric neurosurgeons or obstetricians can run as high as $1,000 an hour. And if attorneys have to cancel a deposition at the last minute, Mr. Keller said his organization charges a hefty rescheduling fee.

"They could enforce a subpoena and say we have to show up for free," he added, "but they don't want to make the doctors angry. We haven't gotten any resistance from attorneys at all."

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Tips to bill Medicare patients for preventive care

Many physicians bend over backwards to save their patients out-of-pocket health care expenses. They extend that courtesy to the physicals that Medicare doesn't cover.

To save patients the cost of a physical, some physicians routinely see patients for a complete exam every year, charging Medicare for a level 5 visit instead of charging patients for a preventive exam.

But that's not the right approach, according to Brett Baker, the College's third-party payment specialist.

Instead, you should use a formula to determine how much to bill patients for the noncovered preventive portion of the visit, Mr. Baker explained. (For more information, see "How to bill Medicare for prevention-related care" in the May 2000 ACP-ASIM Observer.) You should charge patients your fee for a comprehensive preventive physical, minus what Medicare allows for the medically necessary and covered part of the visit.

That's the procedure used by Anthony J. Martini, ACP-ASIM Member, a primary care physician in Warwick, N.Y. "I have started combining a preventive medicine code and charge with a 99213, 99214 or 99215 E/M [evaluation and management] code once a year at the time of the patient's annual physical," he explained.

He also reminds patients that Medicare won't cover a portion of their visit and asks them to sign an advance beneficiary notice (ABN), even though patients technically don't have to. (Under Medicare regulations, patients don't need to sign a waiver because preventive services are a noncovered benefit. ABNs are necessary only when it is unclear if Medicare will accept a claim as "reasonable and necessary.")

What success does Dr. Martini have in getting patients to pay their portion of the bill? "Half the folks pay when they receive the balance bill, while the other half calls to question it," Dr. Martini said. "Once you remind them of Medicare's rules and the fact that they signed a waiver, about half of them are agreeable."

The remaining few are generally unhappy, he said, "but most pay eventually because they want me to continue to be their doctor."

Analysts point out, however, that Medicare has started questioning when physicians bill a level 5 visit combined with a preventive exam, particularly if no emergent tests are ordered. Mr. Baker advises physicians to check with their Medicare carrier to see if it prohibits billing a level 5 visit with a preventive exam. If physicians instead bill for a level 3 or level 4 visit, fewer covered expenses are "carved out" of your charge for a comprehensive physical—and patients have to pay more out of pocket.

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