Medicare & Your Doctor

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TERMS OF USE: Each article listed on this page is an original written by Rolando Pasquali; many were published in legal journals and in newspapers of general circulation. Each article is based upon general principles of California Law in existence at the time that it was written. Since the law constantly changes, some or all of the information in these articles might be out of date. Even a small difference in facts can change how the law applies to any situation. No information in any article or on this website constitutes legal advice. Neither these articles nor anything on this website creates an attorney-client relationship between you and this office. If you need legal advice, contact this office or an attorney in your area. To read an article, click on its title. Client testimonials or endorsements do not constitute a guarantee, warranty, or prediction regarding the outcome of your legal matter. This website is from an attorney licensed to practice law in California.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A Tangled System of Codes

- by Rolando Pasquali  

Seventeen hours. Just seventeen hours and here it was, Thursday. If law firm associates died and went to purgatory...this must be it. I knew I’d been working hard, no long lunches, no “breaks” to discuss the 49ers , no nothin’. I’d been there for over half the week, and I only had seventeen “billable” hours to show for it. The law firm required that each attorney “bill” 40 hours per week. If “capturing time was an art” like my supervising attorney used to tell me, I wasn’t exactly a Picasso.

          Nothing could be worse than the billable hours nightmare. Now, here I was a decade and a half after leaving billable hours behind. But I still remembered. Everybody has a sad sack story about their work. I’d thought that, when it came to “billing problems,” young law firm associates had it bad...then I met Dr. Dey.

And you thought HMO’s Played Rough

          Martin Albert Dey, MD (not his real name, but I like the acronym) is a surgeon. Like most of his colleagues, he treats, among others, Medicare patients. He likes his work, at least he used to. Then those friendly folks at Medicare wrote him a letter.

          “Dear Esteemed Colleague” they seemed to chide; Are you sitting down doctor ? Good. We’ve decided to audit you. And you haven’t been a good boy. In fact, you haven’t been a good boy 75% of the time. So here’s the deal...

          Medicare then proceeded to explain that it had audited 25 of his patients who were admitted to an acute care hospital. They’d taken it upon themselves to request and review medical records. Now, they’d determined that he’d over billed to the tune of $25,000.00. These determinations included the unconscionable conclusion that a seriously ill inpatient need only be seen every fourth day by Dr. Dey, the attending physician. Further, the doctor had used “inappropriate” billing codes.

A System of Codes

          Unlike other professionals, who can just detail what they do and bill for it, Medicare Billing is a science unto itself. Current Procedural Terminology (CPT) is a systematic listing and coding system. Each imaginable procedure is identified with a five-digit code. For example, let’s suppose that a doctor excises tissue from a patient’s back. CPT Code 21920 is defined as “Biopsy, soft tissue of back or flank; superficial.” Code 21925 is the same procedure, but “deep.” Code 20206 is for a needle biopsy of soft tissue. “Excision, tumor, soft tissue” would be 21930; “radical resection of tumor”is code 21935 and so on. A doctor bills Medicare by selecting the right code from his/her CPT Code Book. My copy of the book is 384 pages long. Really fun stuff.

          In an audit, Medicare looks at the code billed and compares it to the doctor’s patient chart ( not the hospital chart). If the doctor’s chart can’t “stand alone” to support the need for treatment on that day, they make an initial determination to deny payment. That’s when your doctor gets a “Dear Marty” letter. To a busy clinician, the system seems both oppressive and burdensome.

          It’s kind of like auditing a mechanic’s file. So, you checked the ignition timing, eh? The bill doesn’t contain a detailed explanation as to why you needed to check it. Oh, then you actually road tested the car? Well, we’ll just deny payment for that as well.

          Specifically, the doctor undergoes this: So, you had the temerity to vist a hospitalized patient’s bedside and bill for it! Well, let’s look at your notes. Code 99231 says that your chart must reflect “at least two of these three key components”:

1) A problem focused interval patient history;

2) A problem focused patient exam; and

3) Medical decision making [of a specified level of complexity].

          “Now doctor, you have exactly 4 weeks to provide us with a written response justifying your billings.” Also know that “records created in response to this request are not acceptable.” If you don’t reply, this “Preliminary Notice of Audit Results” will become “Final” and we will send you “Repayment Instructions.” Are we having fun yet ?

Statistical Sampling and Extrapolation

          By the way... doctor...we only audited 25 of your patients during the last 6 months of 1996; but we’ve read Illinois Physicians Union vs. Miller and you should read it too! In fact, it’s great reading. You know what the federal courts say? We get to extrapolate!

          Remember those 25 patients? well, they were only part of your “universe” of all Medicare patients during the second half of that year. Since it was a “statistically valid random sample” of all your beneficiaries and all of your claims during that time period, we’ve concluded from the “sample” that the same “lack of medical necessity” and over treatment existed with regard to all of your patients during that time. We’ve now extrapolated out that you incorrectly coded and over billed for your other patients. So let’s forget about the 25k, lets round it out to a nice, even $51,905.48. Got your checkbook handy?

Collection of the “Debt”

          Under the Social Security Act, Medicare gets to charge 13.375% interest on the outstanding debt. They then gave Dr. Dey 30 days to pay them, in full the extrapolated overpayment amount. If no payment was received, they then wrote: “on [the 40th day] we will automatically offset against any pending or future claims you submit in application to the outstanding Medicare overpayment balance.”

          The letter to Doctor Dey was of course signed... by a nurse! Oh sure, there’s an appeal process. First to a Hearing Officer, then to an Administrative Law Judge and finally U.S. District Court. But all-in-all, I’d rather just be 12 billable hours short.      

Pasquali Law

(650) 579-0100

1220 Howard Avenue - Burlingame, California

 

 

 

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Serving the cities of San Francisco, San Jose, Oakland, Fremont, Antioch, Berkeley, Concord, Daly City, Fairfield, Hayward, Richmond, Santa Clara, Santa Rosa, Sunnyvale, Vallejo, Alameda, Alamo, Albany, American Canyon, Ashland, Bay Point, Belmont, Benicia, Blackhawk-Camino Tassajara, Brentwood, Campbell, Capitola, Castro Valley, Cherryland, Clayton, Cupertino, Danville, Dixon, Dublin, East Palo Alto, El Cerrito, El Sobrante, Foster City, Gilroy, Half Moon Bay, Healdsburg, Hercules, Hillsborough, Hollister, Lafayette, Larkspur, Live Oak, Livermore, Los Altos, Los Gatos, Martinez, Menlo Park, Mill Valley, Millbrae, Milpitas, Moraga, Morgan Hill, Mountain View, Napa, Newark, North Bay, Novato, Oakley, Orinda, Pacifica, Palo Alto, Peninsula, Petaluma, Piedmont, Pinole, Pittsburg, Pleasant Hill, Pleasanton, Redwood City, Rohnert Park, San Anselmo, San Bruno, San Carlos, San Leandro, San Lorenzo, San Mateo, San Pablo, San Rafael, San Ramon, Santa Cruz, Saratoga, Scotts Valley, South Bay, South San Francisco, Stanford, Suisun City, Tamalpais-Homestead Valley, Union City, Vacaville, Walnut Creek, Watsonville, Windsor, and Marin County, San Francisco County, San Mateo County, Santa Clara County, Monterey County, Alameda County, Contra Costa County, Solano County, and Napa County