Signs and Symptoms of Frustration

September 2002
Editorial
John W. McDaniel

The aggravation quotient associated with contemporary medical practice is driving some physicians into risky territory. Normal daily operations are inherently hectic. Add on abundant regulations, increasing expenses, declining reimbursement, and an overall flattening of income. These pressures could tempt the most stalwart practitioner to look for ways to ease the burden. For example, too many physicians shrug off the need for coding compliance programs because the law does not require them. Most practitioners believe they are choosing appropriate CPT-4 codes and providing adequate documentation, yet this often proves untrue when their use of evaluation and management codes is compared with the government’s audit standards. While compliance programs remain voluntary, penalties for infractions are mandatory.
A new study in the May 27, 2002, issue of the Archives of Internal Medicine indicates that a minority of physicians would actually bend insurers’ reimbursement rules. Participants were given one of two hypothetical scenarios in which an insurer denied the patient—a 55-year-old woman with severe angina or a 55-year-old man with moderate low-back pain—a medical service. Seventy-seven percent of physicians surveyed would appeal the decision, 12% would accept it, and 11% were willing to “misrepresent the facts” to get the patient additional care.
The percentage willing to go this last route increased with the so-called
hassle factor associated with the appeals mechanism—as the likelihood of a
successful appeal dropped dramatically from 95% to 50% or when the appeals process climbed from 10 minutes to 60 minutes. Most important was disease severity: 16% would alter the facts for the woman with severe angina; 3% would accept the restriction. Corresponding figures for physicians treating the man with back pain were 7% and 20%, respectively.
Good intentions; dangerous tactics. You can be an effective clinician and patient advocate without jeopardizing your livelihood. Numerous resources are available to improve proficiency in coding and documentation. In this issue alone, we address insurance for compliance failures, answer readers’ coding questions, and make an important correction. We also encourage you to learn from practice audits, the last of three important steps in a solid coding compliance program. Although there is a single-digit chance of being audited, if I were a physician, I am not sure I would be willing to take that risk.
John W. McDaniel
Editor-in-Chief
Toll-free phone: 1-800-764-2633
E-mail: jmcdaniel@premierhealthcare.com