When is a battle not a battle

The title of the article says it all: “The Battle over Billing Codes.”

On Marketplace Tuesday (April 10, 2012), Gregory Warner did a report about one physician who has decided to use the billing codes, known as CPT’s to the maximum effect for maximum revenue. The physician states that by maximizing codes he has increased his revenue “by 70 percent -- hundreds of thousands of dollars per year” by doing the same thing he did.

The article also states that we are paying for medicine the way we have been doing it for years, by procedures. As a business professional, with over 15 years in retail and medicine, I have a question for Mr. Warner. How else are we to pay for services rendered than for the service rendered?

At the end of the segment there is a tease related to ObamaCare:

“So can we get rid of the codes? Well, some doctors and hospitals are already signing up for a new program under the health care reform law that would pay doctors by a lump sum instead of per procedure. “

The new program is the ACO initiative, which is a revised capitation HMO program. A capitation program is where the provider is paid a lump sum at the beginning of a set time frame, usually the beginning of the year, to take care of a patient. What is left at the end of the year, i.e Fee Paid less Medical Expenses = Physician Revenue, is the doc's to keep. But wait: if the care for the patient exceeds the fee paid, can the doctor go back and request more money to take care of the patient? The answer is no, because that would be fee for service. The doctor then has to take money from other patients to pay for the really sick patient or take money from his own coffers. Once the docs realized they were on the losing end in capitation, it went the way of the dinosaurs and the only docs who do capitation today are the ones straight out of med school.

Mr Warner continues:

“But other doctors don't want to give up their independence. Larry Rabon and his family have gotten used to playing the chess game. And if every doctor played as well as they do, then our deficit would really be in trouble. “

Mr. Warner refers to payment for procedure as a chess game, meaning there are winners and losers. The implication is that doctors are “winners” because they want to be paid for their services rendered, as any other service professional. Payment for services rendered is how all services are paid. We pay our hairdresser for a haircut, we pay our tarot card reader for a tarot card session, we pay for a ticket to see a movie or play, etc.

Then as a winner, he states that if all doctors understand the CPT rules and bill as Dr. Rabon does, then it will expand our deficit. I hate to tell Mr. Warner, but with people living longer, 86 is now average, and with the Baby Boomers entering Medicare in droves, that is enough to destroy the Medicare system. Dr. Rabon is not only billing Medicare, which has the strictest billing rules, but also the private insurers in order to maintain his revenue stream.

After years of berating doctors to take coding more seriously, which results in them getting paid for what they do, it is refreshing to find out that one doctor has decided his time has worth.