Government Audit Zealots Putting Coding Before Patient Care

Like most American families with school aged children, our family’s annual flurry of back-to-school preparations includes an annual visit to our child’s pediatrician.  Since we generally must take time off work to fit in the pediatrician’s visit around the flurry of work, carpool and other demands of daily living, like most families blessed with relatively healthy children, we tend  to remember to schedule the visit when prompted by a minor health concern and/or to save up our requests for prescription refills and questions and concerns about minor or chronic health care issues to discuss with the pediatrician while he conducts his annual check of our sons’ height, weight, blood sugar, eyesight, immunizations and other basic health concerns normally included in an annual well child checkup.   Unfortunately, the opportunity for parents to use a single office visit to the pediatrician for a single fee to get caught up with our pediatrician on all current and recurring health care questions and concerns about our child while the pediatrician also conducts an annual checkup appears to be the latest healthcare casualty of Obamacare.

The Obama Administration touts the “Preventive Care” mandates of Obamacare as a key reform that promises to bring down patient suffering and the cost of health care through early detection by requiring group and individual health plans to pay for 100% of a physician’s charge for an annual checkup for each individual without applying any co-payment or deductible,  Obamacare often challenge the value of Obamacare’s preventive care mandates on the grounds that Obamacare doesn’t require health plans to cover and health plans often provide no or limited coverage for many procedures needed to treat conditions detected through these checkups.  Beyond concerns about gaps and limitations on coverage to treat conditions identified through the annual physicals contemplated by Obamacare, however, hyper technical coding and billing requirements for physicians when performing and submitting charges for checkups covered by the preventive care benefit also are raising concerns.

Billing and coding rules approved by the Obama Administration require physicians performing preventive care checkups to separately deliver code and bill preventive care services separate from sick or other care the physician provides to the patient.  While these rules are designed to prevent physicians from inappropriately billing sick or other charges for care that does not qualify for coverage under the preventive care mandate, current coding and billing procedures are pressuring physicians to engage in practices that discourage patients from bringing up emerging health concerns or other health care issues during annual checkups.  For instance, our pediatrician’s office warned us that bringing up other health conditions or concerned during the annual checkup could cause us to incur added charges by handing us a paper when I signed my son for his annual pediatrician’s visit last week containing the following new policy on “Charges for Illnesses During Well Checkups:”

 Charges for Illnesses During Well Check-ups

The passage of The Affordable Care Act (the A.C.A.), or “Obamacare”, made several very positive changes in insurance coverage for children: pre-existing conditions are outlawed and preventative health care, or check-ups, are covered without copay or deductible.

However, a check-up does not include management of common pediatric illnesses such as ear infections, bronchitis, injuries, asthma, etc. In accordance with national guidelines and our contract with your insurance company, these illnesses are coded separately from the check-up and are paid separately. Unfortunately, most insurers are paying for management of an illness during a check-up as a separate encounter and applying copays and deductibles to those charges.

There are only three options when a child scheduled for a check-up has an illness or injury:  have the family reschedule the “sick” visit for another time and pay the copay or deductible at that visit; reschedule the check-up for another time and take care of the illness or injury now; go ahead and take care of the problem during the check-up. The cost to you, the family, is the same, but it is much more convenient to do both during the check-up.

This is a difficult issue and we encourage you to discuss this with our insurance department if you have further questions.

While I applaud providers that make an effort to alert patients about potentially unexpected uncovered healthcare costs like the notification from my pediatrician that our family could incur added charges for asking the pediatrician to address an illness or other health concern during  any annual checkup, I am concerned about the likely unintended chilling effect of the notice, much less the regulations that promoted it, could have on the free flow of information between patients and their physicians and the resulting quality of care delivered during the checkup.

Certainly, my pediatrician’s office delivery of this warning against asking the pediatrician to treat an illness or provide other care in addition to performing the scheduled checkup unless I was prepared to pay added charges prompted me to reconsider the list of topics I planned to discuss during the meeting.  Fortunately, I felt I could afford the potential additional charges that I was likely to incur to get advice on the questions on my list;  however, many American families are not so fortunate.

During the appointment, I discussed both my planned list of concerns and questions, as well as the new policy, with my new pediatrician.  In the course of the appointment, we each also bemoaned the waste of the ACA preventive care mandate forcing health plans to make heavy expenditures to screen patients for a host of disease,  when public and private plans frequently provide little if any coverage to help patients and their families pay for the costs of following on testing, much less treatment that patients would need to treat the condition detected through the checkup covered by the preventive care screening as well as a host of other new challenges for patients and providers fueled by Obamacare.  Both of us agreed that the disruption of the continuity and quality of communication necessary to the patient physician relationship was one of the most significant of these adverse side effects.

Of course, the chilling affect of notifications or other discussions about added care costs are most likely to affect the care decisions of budget-strained parents or patients.  Warnings or other discussions about potential uncovered charges tend to make budget sensitive or otherwise cost-conscious patients or parents think twice about seeking care.  Patients or parents of patients concerned about care costs are likely to be reluctant to bring up health concerns or share other symptoms with a pediatrician or other physician during an annual checkup for fear the discussion might trigger additional unbudgeted charges for the visit in a manner that could undermine the reliability of the checkup, cause a patient or parent to delay seeking care of an emerging condition, or prompt a patient or parent to delay scheduling an annual wellness exam.

However, it is not just budget conscious patients and families that are likely to suffer as a result of the chilling effect of policies or practices that discourage the free flow and open discussion of information between patients and providers, the patient-physician relationship and quality of care.  On the contrary, any policy that requires or encourages a patient or a doctor to fail to exchange and freely discuss information, questions or concerns about current or recent symptoms, illnesses or injuries inherently undermines the quality and value of the encounter. Since any reliable checkup or other treatment generally must include gathering and consideration of information about current or recent illnesses, injuries, symptoms and concerns, a policy or practice that discourages patients and their caregivers from openly sharing, physicians or other caregivers from holistically collecting,  or patients, caregivers and physicians and other health care providing from openly discussing past, current or recent symptoms, illnesses or injuries during a checkup or any other visit inherently undermines the value of the checkup as well as the overall quality of care provided to the patient. The Obama Administration, as well as patients and their caregivers, health care providers, employers, health plans and American communities all share an interest and must work together to identify and insist that appropriate steps be taken to ensure that health care billing, coding or other laws, regulations and practices do not allow excessive emphasis on billing accuracy to undermine care quality generally.

Do you share these or other concerns about how Obamacare or other federal or state reforms are affecting the patient-physician relationship or other aspects of our health care system, its quality, affordability or access?  How are you as a patient or family member of a patient, employer, healthcare provider, or health plan or insurer dealing with these encounters or concerns?  If you found this article helpful and are interested in learning about or joining the discussion of health care, aging and disability related public policy reforms as well as  practical practices, tools, information and ideas for helping disabled, aging or ill individuals, their families and other caregivers, and communities to anticipate, plan for and meet the challenges of living with or caring for ill, disabled or aging individuals, register to follow the resources and discussions of Project COPE: Coalition for Patient Empowerment here and join and participate in the sharing of information, exchange of discussion and prespectives, tools, opportunities for collaboration and participation, and other resources available through our involvement in our Coalition For Responsible Health Care Policy LinkedIn Group. You also be interested in reviewing one or more of other recent articles published on the Coalition For Responsible Health Care Policy  electronic publication available here, our electronic Solutions Law Press Health Care Update publication available here, or our HR & Benefits Update electronic publication available here.  You also can get access to information about how you can arrange for training on “Building Your Family’s Health Care Toolkit,”  using the “PlayForLife” resources to organize low-cost wellness programs in your workplace, school, church or other communities, and other process improvement, compliance and other training and other resources for health care providers, employers, health plans, community leaders and others here. If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail by creating or updating your profile here.

About Project COPE: The Coalition On Patient Empowerment & Its Coalition on Responsible Health Policy


Project COPE: The Coalition on Patient Empowerment (Project COPE) & the Coalition on Responsible Health Policy (Coalition) are Solutions Law Press, Inc.™-sponsored public policy and community service projects that seek to empower ill, disabled and aging individuals, their families and other caregivers, employers, health care and other disability services providers, employee benefit plans, insurance and other payers, communities and community service organizations, government agencies and programs and other stakeholders individually, and our society collectively to better understand, identify, plan for, constructively collaborate and work together and respond to the challenges and responsibilities of meeting the needs of ill, disabled and aging individuals in our society encouraging and promoting better awareness, understanding, collaboration and teamwork, public and private policies and practices, skills, resources, support and tools and other understanding, collaboration and actions that better empower ill disabled or aging Americans, their families and caregivers, healthcare and disability service providers, employers, insurers, communities and community organizations, government agencies and officials and policymakers and other stakeholders as well as our society as a whole to understand, plan for and cope with the challenges and responsibilities they face in responding to illness, aging and disabilities.

Project Cope and the Coalition recognize the challenges or, and how our society addresses the needs and challenges of caring for the ill, disabled, and aging members of our society often has broad reaching impacts on ill, disabled and aging individuals and their family or other caregivers, as well as friends and neighbors, taxpayers, employers, benefit plans and insurers, health care and disability service providers, communities and community organizations, social service and other governmental agencies, and others all are impacted by, bear responsibility for, and play a critical role in planning for, providing and helping to cope individually and collectively with illness, aging and disabilities in our families and communities.

The Coalition For Responsible Health Care Policy focuses on public policy, regulatory, tax, enforcement and other government actions that shape and impact the care and treatment of aging, ill and disabled people in our communities and others caring for or dealing with them.  The Coalition exists in recognition of the significant direct and indirect impact that Federal and state health, disability, employee benefit, insurance, employment, tax, social security, civil rights and a host of other laws, regulations, funding, enforcement and other government policies and actions have in shaping the responsibility for, experience, availability, quality, cost and financing, delivery and other elements of the care and treatment of ill, aging and disabled Americans, their families and caregivers, healthcare and disability services providers, employers, insurers, their communities and community organizations, taxpayers, social and other government agencies and other stakeholders and the ability of stakeholders to predict, plan and pay for and cope with the challenges of illness, aging and disabilities.  The Coalition seeks to promote the development and implementation of synergistic statutory, regulatory, funding, enforcement and other healthcare, disability, aging and other policy by encouraging constructive awareness, understanding, involvement, vetting and input, consensus building, and other participation among other stakeholders throughout the process through a variety of activities including:

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While acknowledging the importance of striving to improve public policies impacting responsibility for and the financing and delivery of care of ill, disabled and disabled individuals within our communities and society, at the end of the day, public policy can only do so much.  The best public policy solution only facilitates, obstructs or assigns responsibility or blame for financing the cost, caring for and dealing with the ill, disabled and aging in our families, workplaces and communities among the various individuals and organizations within our society.  At the end of the day, ill, disabled and aging individuals and their families and caregivers, their employers, healthcare and disability service providers, governmental agencies and communities still are left to deal with the day to day realities of dealing with and fulfilling their assigned responsibilities to care for ill, aging and disabled individuals and their families.

Project COPE focuses on empowering ill, disabled and aging individuals, their families and caregivers, employers, health care and disability services providers, communities and community services agencies, government and government agencies and others to better and more effectively plan for and cope with their own challenges and responsibilities by developing and promoting the use of understanding, practical tools and resources, communication, organization, collaboration and teamwork and other skills and abilities that aid them to better cope with the realities of their responsibilities and roles for caring for or dealing with ill, disabled or aging individuals or their family or caregivers including:

  • Educating and helping individuals and organizations to understand their own and the abilities, resources, responsibilities and challenges of the others involved in caring for or dealing with ill, disabled or aging individual and his family and caregivers;
  • Developing, sharing and encouraging the use of resources like our “Building Your Family’s Health Care Toolkit” training and tools, “PlayForLife” resource for helping to plan low-cost wellness programs in your workplace, school, church or other communities, health care teamwork and communication, and other process improvement, compliance and other training and education, needs assessment and planning, practical organizational, skill building, care coordination and management, communication and other tools and strategies that help patients and their caregivers, employers, health care providers, payers, communities, governmental leaders and other develop and improve their own understanding and coping skills for dealing with illness, disability or aging;
  • Working with all parties to improve their understanding and knowledge, effective communication, teamwork, collaboration to better plan for and cope with their own challenges and responsibilities of planning for and caring for themselves or others impacted by illness, aging or disability and work together collaboratively to meet these challenges and leverage these opportunities individually and collectively; and
  • Hosting,  helping to organize, providing or helping to identify speakers or other resources for conferences, workshops, and other events and activities that help to promote communication, organization, collaboration, planning and other skills and understanding that providers, patients and their caregivers, employers, health plans, communities, the government or others can use to better plan for or meet needs and challenges associated with caring for ill, aging or disabled individuals;
  • Working with disease management organizations, health care providers and organizations, employers, insurers and communities to understand and better meet various challenges of dealing with illness, aging or disability on their responsibilities and activities; and
  • A host of other activities.

You also can get access to information about how you can arrange for training on “Building Your Family’s Health Care Toolkit,”  using the “PlayForLife” resources to organize low-cost wellness programs in your workplace, school, church or other communities, and other process improvement, compliance and other training and other resources for health care providers, employers, health plans, community leaders and others here. If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail by creating or updating your profile here.

For important information about this communication click here.

©2016 Cynthia Marcotte Stamer.  Nonexclusive right to republish granted to Solutions Law Press, Inc. All other rights reserved.

One thought on “Hyper-Technical Health Reforms Threatening American Family’s Health Care Quality

  1. Excellent points and thank you for the discussing these issues.

    As a physician in the direct care movement, my patients pay $10/mo /child for unlimited office visits, phone calls, emails, text messages; no copays for anything, any office procedure we can do is free of charge, and we provide wholesale pricing for medicines and labs.

    Our families can schedule 30-90 minutes (or more if needed) to discuss their whole families care, complete sports physicals, discuss acute and chronic concerns etc.

    I can’t imagine going back to the insurance model and having to tell parents that they have to make these kind of decisions about how and when to access their physician and care for their families.

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