Medical Billing Question

[JACKie SPARROW]

Here is my situation. DH went to see his physician for a few medical conditions which require him to take medication. The physician checked him out and renewed all of his prescriptions. Becasue he is being treated for health problems, can the physicains office bill the visit as routine?

Thanks for your help

 

[PammieJ]

Hi, Jackie. I'm a medical coding supervisor for a seacoast NH medical facility, where I code/bill for over 90 physicians. I've been doing this for over 20 years, so I'm pretty close to being an expert.

Regarding your question: The short answer is 'maybe'.

What kind of visit was your husband scheduled for? If the intent of the visit was for a routine checkup (i.e. annual physical), then yes, the visit can be considered routine. During that visit, your physician can definitely also address any chronic conditions that your DH has; those diagnosis codes would also be reported, but secondarily, since the reason for the visit in the first place was for routine care.

If he was scheduled for an office visit specifically to review his chronic conditions, it would never be appropriate to consider this 'routine'. Identifying a visit as 'routine' when there is the presence of symptoms or an established diagnosis is considered inappropriate billing. I woud then ask the billing office to review the claim, and resubmit it as a corrected claim.

Hope this helps. PammieJ.

 

[JACKie SPARROW]

Hi, Jackie. I'm a medical coding supervisor for a seacoast NH medical facility, where I code/bill for over 90 physicians. I've been doing this for over 20 years, so I'm pretty close to being an expert.

Regarding your question: The short answer is 'maybe'.

What kind of visit was your husband scheduled for? If the intent of the visit was for a routine checkup (i.e. annual physical), then yes, the visit can be considered routine. During that visit, your physician can definitely also address any chronic conditions that your DH has; those diagnosis codes would also be reported, but secondarily, since the reason for the visit in the first place was for routine care.

If he was scheduled for an office visit specifically to review his chronic conditions, it would never be appropriate to consider this 'routine'. Identifying a visit as 'routine' when there is the presence of symptoms or an established diagnosis is considered inappropriate billing. I woud then ask the billing office to review the claim, and resubmit it as a corrected claim.

Hope this helps. PammieJ.

Thanks for your response. Unfortunately, I guess we should have asked questions regarding the office visit. DH is on meds when the refills ran out. The office called and told him to make an appointment, so he did. The office just sent us a bill from last April which the claim was denied.

The upsetting part of this is that there has been no one doing the billing on a regular basis. If the receptionist has time she does the paperwork; when claims come in from the ins. co. they sit on the desk until someone has time to enter them. I called to inform them that he was seen for multiple problems and left with prescriptions so it shouldn't be billed as routine. Now, I was told that they do not want to rebill it because they wouldn't get as much money from the ins. co. If there were an actual diagnosis and they would have to send money back and they are not sure how to do that.

The office just called and wants DH to make an appointment; here we go again! I think I will call and demand answers, otherwise I am considering having DH see a new physician.

 

[PammieJ]

You definitely should contact your insurance company, and here's why.

When physicians sign a contract with an insurance company to agree to see those patients (usually at a set fee), they are bound to follow all published and required coding guidelines. If your doctor's office is billing inappropriately, this is a violation of their contract with the insurer. There's no reason why you should get stuck in the middle, and if I were you, I'd make a fuss. A big fuss. Believe me, your insurance company will be all over that employee like a cheap suit. Why should you be responsible for your physician's poor billing practices?

The doctor's employee's response was absolutely outrageous. By refusing to send a corrected claim, because she "doesn't know how to refund the money", is a line of bull...... I am confident that the insurance company will make it crystal clear, by sending a letter to your doctor's office, demanding re-payment. What the heck planet is this person on, anyway?

Let me know how this goes for you. good luck. PammieJ.

 

[debbiecarr98]

You definitely should contact your insurance company, and here's why.

When physicians sign a contract with an insurance company to agree to see those patients (usually at a set fee), they are bound to follow all published and required coding guidelines. If your doctor's office is billing inappropriately, this is a violation of their contract with the insurer. There's no reason why you should get stuck in the middle, and if I were you, I'd make a fuss. A big fuss. Believe me, your insurance company will be all over that employee like a cheap suit. Why should you be responsible for your physician's poor billing practices?

The doctor's employee's response was absolutely outrageous. By refusing to send a corrected claim, because she "doesn't know how to refund the money", is a line of bull...... I am confident that the insurance company will make it crystal clear, by sending a letter to your doctor's office, demanding re-payment. What the heck planet is this person on, anyway?

Let me know how this goes for you. good luck. PammieJ.

Absolutely agreed. I have worked in a medical office most of my life. This is totally inappropiate and it should not fall on your shoulders because of their inefficiency. I would contact your insurance right away. What a stupid statement for them to make!! You should be sure and tell the insurance company exactly what they said. That is really unprofessional, and unethical.

 

[LMC]

Since you just got a bill from LAST April I would be concerned that they did not file it timely based on the info you gave that it sits there until someone can do it. I am in school for my two year degree right now in Health Info Mgmt and I believe we learned that there is a time limit for when claims can be filed. PammieJ can clarify this. Is it possible that they missed the window and can't get the insurance to pay it so they are trying to stick it to you now? I would get with the insurance co to find out when they filed it, when it was rejected, why, etc. If they missed the cutoff and are trying to get you to pay it that is a big no no with the insurance company too.

Thanks for your response. Unfortunately, I guess we should have asked questions regarding the office visit. DH is on meds when the refills ran out. The office called and told him to make an appointment, so he did. The office just sent us a bill from last April which the claim was denied.

The upsetting part of this is that there has been no one doing the billing on a regular basis. If the receptionist has time she does the paperwork; when claims come in from the ins. co. they sit on the desk until someone has time to enter them. I called to inform them that he was seen for multiple problems and left with prescriptions so it shouldn't be billed as routine. Now, I was told that they do not want to rebill it because they wouldn't get as much money from the ins. co. If there were an actual diagnosis and they would have to send money back and they are not sure how to do that.

The office just called and wants DH to make an appointment; here we go again! I think I will call and demand answers, otherwise I am considering having DH see a new physician.