Docnotes: Billing woes ...

A few weeks ago, I pointed to an article on billing for mental health services in primary care. I was surprised that the author suggests that primary care physicians can use 908XX CPT codes. I've never done this, and asked our medical director what he thought. His initial response:

.... many/most of our health plans will likely not reimburse us for these services because of their requirements that mental health diagnoses be treated within their mental health network. If Medicare were to pay, they would pay at the reduced mental health rates. So, it doesn't sound like a good idea any way you look at it.

My morning project confirmed his thoughts .. and then some. It gave me a little glimpse of what our billing staff attempts to deal with on a daily basis ... and is a great example of why our health system is simply broken.

Better rewind to March, 2003 to catch you up.

I see a patient with bipolar disorder in the office for a follow-up visit. I had initially referred him to a psychiatrist for help in confirmation of the diagnosis, and support in medication selection. After about 8 months, the patient was doing very well and asked if he could follow-up with me for this problem and monitor his medication levels, etc. Both the psychiatrist and I felt that this would be just fine.
So our first follow-up visit went well, and I coded the visit with a 99213 and an ICD-9 code consistent with the diagnosis. Bill goes out for $74
The bill went to the primary insurance company, but since an ICD-9 code that was consistent with a mental health diagnosis was used, the charge was denied. The patient's insurance coverage dictated that all mental health benefits be managed by another company rather than the primary medical insurer. So after our billing department got the denial, the bill was re-sent to the other company.
Since the other company doesn't have me on their list of "in-network" psychiatrists, the charge is applied to the patient's deductible. (not yet met) So nothing is paid.
Now it's 6 months later ... 11/03
Our billing office sends patient a bill. 12/03
Our billing office sends patient a bill. 1/04
Our billing office sends patient a bill. 2/04
Patient is mad. Has called us a few times .... we call insurance company ... patient told by our billing office that this is not paid by insurance since deductible for mental health services wasn't met .. so they need to pay the balance of $59 ($15 already paid .. patient's co-pay).
Patient calls insurance company - who tells patient that physician made billing error, submitted wrong code. If we re-submit with "a medical code" then bill will be paid.
... more of the same ... now it's 6/22/04 .. my day off .. billing specialist asks me if I want to write off the $59 since the patient is on the phone and still very angry about bills from us that keep coming.
I have 10 minutes at home to call insurance company. I don't think I made any error. Coded accurately for a diagnosis that is appropriate to be managed in primary care. It's not like I coded for a psychotherapy CPT (I'd never DREAM of making that mistake .. despite the article in PCC!)
- Call provider services number. Navigate through voicemail. Enter my tax ID number, patient's SSN, patient's date of birth.
- Wait on hold 15 minutes
- Talk with human who tells me I have to call another number.
- Repeat process above - waiting on hold only 10 minutes this time
- Human answers ... reviews bills with me and suggests that we re-submit bill with a "medical code" such as insomnia or fatigue. She explains that the psychiatric ICD-9's go automatically to the mental health services company.
  - So any time I code for depression or anxiety you won't pay?
  - No .. we'll pay for it just fine
  - But this got denied
  - Yes .. because the mental health services company didn't deny it
  - It sure feels like they denied it.
  - Well, they didn't send it back to us
  - Why not?
  - Because they applied it to deductible since you're out of network
  - No I'm not .. I'm in your network
  - But your not in their network of psychiatrists.
  - Of course not
  - So If they had denied the claim AND sent it back to you .. you would pay it?
  - yep
  - OK .. how can we make them send it back to you
  - why don't you try re-submitting it.
- Re-submission was not something I wanted to embrace and I politely explained that I was not hanging up until we had all figured out a solution right now .. rather than rolling the dice. After about 15 minutes on hold .. and some more conversation, we got the representative from the other company on the phone. She couldn't help us, and felt that everything had been done properly and that the patient was responsible for the balance. I suggested that this was simply crazy, as it would mean that primary care physicians would never be paid for mental health ICD-9 codes.
- At this point, she volunteered the same suggestion the other representative had shared: I should be using a "medical" code describing the symptoms rather than a more accurate (and legitimate) mental health code.
- I suggested that this would be fraud and she shut up about that and agreed that no one is suggesting that I submit a fraudulent code.
- (Medical) health insurance lady brings up a secret (to me) clause that says that the patient gets six mental health visits covered under the medical insurance .. before mental health coverage should be invoked ... so mental health company should have denied the charge based on the fact that there were fewer than six mental health claims. The denial from mental health company would then cause the bill to go back to medical company .. where it would be paid.
- (Mental Health) insurance lady thinks about this a minute and then says it won't work.
- So I ask for supervisor
- She puts us on hold (So I'm on hold with medical insurance lady .. and it becomes clear that she is motivated to get this claim back into her company so she can just pay it).
  - Supervisor is in a meeting, please hold a bit longer.
  - Supervisor still in a meeting, but I asked her and she says go ahead ... so we will deny the claim based on six visit rule and you should have it back to medical insurance company within a few weeks.
- I suggest that "should" and "a few weeks" are not reassuring to me and that we really ought to be able to get it back right now ..
  - how about you two exchange fax numbers and we take care of this now?
- (Mental Health) insurance lady:
  - I'll put this in the system and request that it be done soon
  - (me:) ... uuh .. no .. I'd like you actually DO it instead of plopping it in someone else's lap to take care of later.
  - OK

So it took a bit more than 90 minutes of my time this morning to get paid on a $59 balance from 15 months ago. Our billing specialist spends her days like this. We have thousands and thousands of dollars of write-offs every months ... for things that we just don't have the energy to follow-up on. The system is simply broken. Every company comes up with their own methods of trying to deal tactically with the small problems they see .. and of course, we respond with our own tactics .. such as hiring billing specialists to argue with theirs.

But what in the world does this have to do with health-care? Oy ... not much. Will I hesitate before coding for mental health ICD-9 codes? yep. Primary care of the future: