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Payers know that correctly writing down every patient encounter is difficult for physicians, if not impossible. Therefore, exploiting this is easy for them.
I have been thinking about CPT codes and chart documentation this week. Friedrich Nietzsche said I probably shouldn’t do this: “Gaze long enough into the abyss, and the abyss gazes back.”
Staring at the abyss is probably easier for me than it is for my physician clients. At least the abyss doesn’t reach up, grab hold of me, turn me upside down, and violently shake every last nickel from my pockets. That’s what the system is doing to physicians.
It all started so simply. When the AMA came up with the idea in 1966, CPT codes were intended to simplify charting and streamline reimbursement. Great idea. This would not only solve the problem of questionably comprehensible penmanship, it would also mean people who speak different languages would understand each other.
CPT coding would allow physicians to get the point across quickly, accurately, and with the least amount of writing. Perhaps too little writing. All practices would have to do is send in the claim form, or electronically file, and the check would arrive in the mail, or bank account, in no time.
Then, something bad happened. Apparently, the people writing the checks began running short on cash.
In a true free market exchange, this problem would solve itself. When people run out of money, they either run up debt, or stop spending. The asking price must then be lowered, until there is a market for services, at that new lower price.
In a third-party reimbursement model, things don’t work that way. Patients need care, and nobody forces them to stop (or at last tap the brakes), until the system replenishes itself.
Cash-strapped third-party payers, whether self-funded or fully insured plans, found something else to stand in the shoes of free-market supply-and-demand economics. If CPT coding streamlines cash flow, then one solution might be to frustrate and delay cash flow by attacking the weakest spot. Payers have long known that correctly writing down every patient encounter is difficult, if not impossible. Therefore exploiting this should be easy; and it is.
Auditors, working on behalf of insurance companies are sending letters, requesting documentation on a certain number of cases. Nobody’s perfect, and that’s the weakness. If a certain code requires documentation of a set of criteria, and one is missing from the chart, then the claim will not be paid. Enough bad grades, and a physician may be placed in prepayment audit status, in which documentation must be submitted with the claim. This takes weeks, if not months longer to process.
While there are cases of fraud and abuse which need to be monitored, I am beginning to suspect we are seeing a game of “gotcha,” where payers are informing physicians that previously approved claims are being recouped.
Practices simply aren't putting maximum effort into a task that CPT codes were supposed to minimize. That seems strange to me.