A Glimpse at the Evolving State of Healthcare

"There have been major changes to the codes (effective January 1, 2013) in the Psychiatry section of the American Medical Association’s manual on Current Procedural Terminology (CPT). These are the codes that must be used for billing and documentation for all insurers. Note: These coding changes apply to all services as of January 1, 2013. For dates of service through December 31, 2012 use the 2012 codes. "

A number of articles posted recently on FR have focused on the simultaneously imploding and exploding aspects of our country's healthcare system, and the role that the powers that be are playing in its demise. Articles here have also explored the role of mental illness in gun-related violence, and violence and mayhem in general in our society, and wondered what can be done about it.

I'm an MD. My specialty is psychiatric medicine, "psychiatry." I thought it might be instructive to lay people to catch a mere glimpse into but one aspect of the increasingly byzantine regulations under which my specialty must practice, regulations which can then easily be extrapolated out to all the other specialties.

The most fun can be had by hitting the links and downloads offered on this page, especially the "Chapter 4" link in the first bullet point under E&M half way down the page for starters, affording one a Mr. Toad's Wild Ride down the rabbit holes and worm holes that comprise the labyrinth of this alternate universe.

Imagine juggling all these balls in the air while trying to sort out the person's problem, and how best to help them. Imagine the time spent in documentation, and the likelihood that it will never quite suffice to prevent an investigation into federal felony charges. Think of this next time you sit in the office with your doctor.

For those who come back from this exploration wanting more, a perusal of Ms. Sebelius' official pronouncements from the HHS web site might be even more frighteningly instructive.

My wife is a CPC and deals with this for her psychiatric group daily. The best is when even though all the codes are correct and billing filed correctly the insurance companies and Medi’s play the delay and re file game as long as they can to keep the physician from being paid the small percentage of what was billed.

The insurers have no incentive not to behave this way: the docs and the staff are powerless, and in my experience the patients paying the premiums have little real power either.

Years ago I had a small private practice in a small town, a small town in which a significant number of people lived on trust funds. I worked fee for service - A check or cash was handed to me at the outset of each visit, and a receipt was given to the patient with the diagnosis, type of service rendered, and the amount collected. The patients, who certainly had more - but still limited - clout with the insurers were able to then fight it out with on their own, and I could focus on the task at hand. It was a very “clean” way to practice.

Increasing numbers of docs are going to this model lately, and I suspect I soon will as well, unless I just retire a bit early. Sadly, I’m afraid, that sort of practice will soon be outlawed as well, if I read the omens correctly.

From the point of view of the customer the whole medical billing system fell down the rabbit whole a long time ago. We regularly see bills from providers with wildly inflated prices, typically 5 to 6 times what the provider accepts as full payment once the invoice is filed with an insurance provider. If any other business tried that you'd be hounded out of business by the government, or charged criminally.

The latest trick is for hospitals to buy a doctor's practice and then slap "facilities" charges on to the bill for the visit to the doctor's office. This has the effect of doubling the bill in most cases, although your visit to the doctor really had nothing to do with the hospital.

I have a bill on my desk where a $200 routine office visit has a $284 "facility fee" associated with it. Put in perspective, that's over $500 per hour for the privilege of sitting in the waiting room. And the hospital doesn't even own the office, it just happens that a doctor who they employ has his office there.

I'd like to see what would happen if some restaurant charged its customers a "facility fee" of $500 per hour for the time they were eating their hamburger.

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