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Friday, September 25, 2009

Records requests: Answer carefully

Your practice probably receives multiple requests for records each week. Unfortunately, more and more of these requests are related to your claims for payment. With ever-growing reports of waste and abuse in health care and profits to be made in recovering money paid to physicians and other providers, these requests are not going away. Whether from Medicare administrative contractors (MACs), recovery audit contractors (RACs), Comprehensive Error Rate Testing (CERT) program contractors, private payers or Medicaid plans, how your practice responds to these requests can make a big difference in your practice's financial future.

So the first question is, who responds to these requests in your practice? Do they understand the importance of sending the right records to support the services billed and doing this in the time period specified on the request? Many of you may be familiar with the CERT program that the Centers for Medicare & Medicaid Services (CMS) commissioned to review the accuracy of claims paid by their Medicare contractors. Some of the most common reasons for errors in the program are these:

  1. Records not sent.
  2. Records sent but not for dates or services billed.
  3. Records illegible or unsigned.

If your practice doesn't provide the records to substantiate your charges, the claim is found to have been paid in error. Medicare contractors are obligated to recover money paid in error. Auditors working for private payers are incentivized to recover money paid in error.

The second question is whether you have a process for making sure that all documentation is provided to support the charges in question. If not, it is probably time to implement one. Here are some tips that might help:

  • Identify a primary and back-up staff person to receive all records requests related to claims or payment.
  • Create a log identifying the date the request was received, the type of records requested and the date the records were sent.
  • If there is any question whether documents are legible or sufficient to support the services that were billed, the physician or other provider of services should review the records and provide a transcribed copy of the documentation in addition to a copy of the original documentation and/or a letter explaining any additional information that may have bearing on the outcome of the review. (Any addendum to the original documentation should be signed with the current date added.)
  • Create a checklist to be used in confirming that copies are ready to be mailed.

Establishing a formal process for responding to requests for records may provide a framework for ensuring that all are appropriately and efficiently handled and help to identify recurring gaps in documentation. It may also protect money already paid to you as well money that you are due.

There are already too many opportunities for practices to lose money in the insurance billing process. Most practices can't afford to take lightly efforts by Medicare and others to recover money they have already been paid.

Wednesday, September 16, 2009


I am trying to figure out why family physicians choose to contract with health plans. 

My pondering of this question is prompted, in part, by an article, "What Does It Cost Physician Practices to Interact with Health Insurance Plans," which appeared as a web exclusive on May 14, 2009, in Health Affairs. According to the article, primary care practices spent $64,859 annually per physician – nearly one-third of the income plus benefits of the average primary care physician – on interactions with health plans. The article also notes that primary care physicians, especially those in small practices, spend larger amounts of time interacting with health plans than physicians in other specialties.

Why would a family physician voluntarily spend almost $65,000 per year for the opportunity to interact with commercial health plans? What do family physicians think they are getting for their money?

The article suggests that there are benefits to these interactions. For example, the authors point out, prior authorization and formulary requirements may reduce costs and improve the quality of care by reducing the inappropriate provision of services and promoting the use of appropriate procedures and medications. That may be, but somehow, I doubt that's why family physicians buy into the process. After all, $65,000 per year would go a long way toward the purchase of an EHR with decision support tools and electronic prescribing, which might also achieve the same results with less aggravation in the long run. 

Some might suggest that family physicians don't "choose" to contract with health plans, that they have to do so for their practices to be viable. In this view, health plans are like some sort of health insurance Mafia that make family physicians "an offer they can't refuse" to ensure their practices stay open. Given the relative bargaining strength of family physicians and most health plans, this view is understandable. 

The corollary to this answer is that if a family physician chooses not to contract with health plans, he or she won't have any patients, or at least not enough to sustain the practice. The premise here seems to be that patients do not value the services of family physicians beyond the co-payment most of them currently must pay for an office visit. 

However, there are some problems with this answer and its corollary. One problem is that there are examples of family physicians who have successful cash-only practices, and I'm not talking about the kind of practices that only cater to the lifestyles of the rich and famous. Family Practice Management has highlighted some over the years; for example, see "2,500 Cash-Paying Patients and Growing" in the February 2006 issue. 

Another problem is that it's not clear where else all of these patients would go if family physicians opted out of contracting with health plans. According to a one-pager produced by the Robert Graham Center, family physicians and general practitioners provided 24 percent of the average 838 million visits per year provided by all physicians in 2003. If my math is correct, the rest of the system would have to increase its capacity by one-third to cover all of those visits, if patients decided not to see family physicians because they didn't accept insurance. I find it hard to believe that is possible.

I understand that the counterpoint here is that contracting decisions are made at the individual practice level, not the level of the specialty as a whole. In other words, family physicians contract with health plans because they are afraid that if they don't, their patients will go to their colleagues who still do. I understand that counterpoint to mean that family physicians choose to contract with health plans because their colleagues do, from which one might conclude that if their colleagues jumped off a cliff, most family physicians would do the same.   

A third problem with the "I-can't-afford-not-to" argument is that it runs contrary to what family medicine is saying and has evidence to support regarding the value of family physicians. Much of what is being discussed in the context of health care reform shows buy-in for the notion that there is value in primary care, and proposals on Capitol Hill would spend billions on primary care, including family medicine. Yet, interestingly, many family physicians seem convinced that patients won't pay more than $25 for their services. 

The only remaining answer I can discern to the question of why family physicians contract with health plans is that they are making money on the deal. In short, it must be worth more than $65,000 per year to contract with health plans. I would find this answer more convincing if family medicine did not consistently rank near the bottom of earning lists by specialty. I would also find it more convincing if the percentage of U.S. medical student graduates choosing family medicine was higher or trending upward. 

In the end, the more that I ponder the question of why family physicians contract with health plans, the less that I think I know the answer.

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