I am in lovely Columbus, OH, about to meet Dr. Lander, Donelle Holle, and some clients for dinner as we prepare for our pediatric coding and practice management event tomorrow morning. We obviously won’t have the crowds we get in Washington or NYC, but it will be a pretty full room still! If you are one of the blog readers, say hello.
Two vital pieces of pediatric insurance information for those of you who aren’t PEDCOUNCIL members or on the SOAPM mailing list.
UHC moves to enhance immunization administration payments
After receiving input from the AAP regarding low immunization administration pricing, UnitedHealthcare (UHC) found the main reason for this is that pediatricians are on contracts with fee schedules tied to 2004 CMS Medicare rates or prior years. UHC reported that, to a lesser extent, it also found that some markets set immunization administration pricing at a lower percentage of the CMS Medicare rates. Most markets are currently using 2008 CMS for physician contracting. UHC has identified those pediatricians whose contracts with fee schedules set at or prior to the 2004 CMS Medicare rates and will be working over the next several months to update the fee schedules and migrate those impacted to a more current CMS year in order to increase immunization administration pricing.
UHC will provide written notice of the fee schedule changes for immunization administration codes in conjunction with other fee schedule maintenance in some cases per the terms of the contract. UHC expects that this initiative will take several months in order to complete financial analysis, complete the revised contracts and mail to physicians, load the new rates and provide the appropriate notice per the contract.
The AAP will continue to dialogue with UHC regarding the timing of the effective dates of the updated fee schedules and to monitor UHC review of its vaccine payment methodology.
As follow-up to a recent meeting with the AAP, Humana has announced that it will revise its pediatric immunization payments, as well as pay for telephone care.
Vaccine payments: As of October 1, 2008, Humana will increase payment for pediatric immunizations that will based on a percent of the current average sales price (ASP). Humana will also reimburse vaccines that are not based on ASP to a percent of average wholesale price (AWP). Details regarding reimbursement on the Humana National Drug and Biologicals Fee Schedule can be viewed by participating providers via the secure area of www.Humana.com ( http://www.humana.com/ ) In addition, for pediatric combination vaccines containing four or more vaccine components, Humana will pay the immunization rate plus an additional $11 to the allowable fee. This would not apply to those combination vaccines with fewer than four vaccine components (e.g., MMR
This reimbursement methodology applies only to providers that have either received written notification or signed an addendum indicating transition to the Humana National Drug and Biologicals Fee Schedule. For more information regarding the transition to the national drug schedule, please contact the Humana contracting representative in your market.
Telephone care: Humana has established processing rules for the new telephone CPT codes 99441-99443. these codes will be processed as covered services; however, the and the plan member will be responsible for standard office co-payments or other cost-share amounts applicable to any other office visit. Medicare does not cover those telephone consultation codes nor does the Department of Defense (TRICARE) so neither Humana Military Healthcare Services (HMHS) nor Humana Medicare will cover the telephone care codes. Only Humana commercial health plans will provide payment for telephone care. Payment for the telephone consultation codes will be based upon the current RBRVS system.
For information on coding and billing for telephone care, see the AAP Payment for Telephone Care Toolkit, available on the PMO at: http://practice.aap.org/telecarepmt.aspx
AAP private payer advocacy will continue to work with Humana and shareadditional details of these payment enhancements.
A lot to comment about.
Honestly, I am going to tell all my friends to choose Human if they can. Not because these dollars make some huge difference, but because it’s a sign that someone in that company gets it and they should be applauded.
More tomorrow, perhaps “live” from the coding conference!
I was paging through my daily Verden Alerts and I noticed that Harvard Pilgrim had released a new set of payment policies regarding E&M codes. In fact, you can read it here on their WWW site, Verden just makes this a lot easier. I suspect that most of you are like me and wouldn't normally take more than a second or two to go through the details of their announcement, but something drew me to it and I read carefully. This part jumped out at me:
Harvard Pilgrim reimburses two telephone E&M services (5–10 minutes of medical discussion) per calendar year for members with associated behavioral health diagnosis, for the purposes of medical management.
Whoa, since when? That's news to me. Another payer, picking up the phone codes! And are our MA clients billing it? Let me ask. Client number one:
"No, I had no idea!" [You know who you are.]
Client number two:
"I thought I'd heard about that..." [You know who you are.]
OK, so it appears to be limited to patients with associated behavorial health diagnoses (whatever that means), but this is such a good example of how it's so easy to get overwhelmed with what you need to know.
It's also - and take this as a sales pitch - proof that all it takes is one good message from Verden to pay for itself every year. It's like the GPOs - why are people not using these services? I called Susanne and asked, "How long have they been paying this code?" Sure enough, she can check her archives in two seconds and said, "It was in their October, 2008 announcement." Thus, our clients have had three months to prepare for this change, yet they don't appear to be taking advantage of this fairly revolutionary code.
I've mentioned the use of telephone codes in pediatric offices a few times previously, but it looks like I may have never actually provided any usage data! It just so happens that the a good friend asked me, "Are most insurance companies paying for the 96110?" which made me wonder about any changes to the phone codes. [More about the 96110 tomorrow.]
Although the numbers show an improvement, they are still depressing. First, the codes I'm talking about: 99441, 99442, 99443 and the new telephone codes 98966, 98967, and 98968. If you don't know what these codes are, they are easily Googled and learned about. I will just assume you know.
First, fewer than 20% of PCC clients even use these codes. Fewer than 10% of PCC clients have used these codes more than 20 times. And only one used the codes more than 100 times. That's right - even though these CPT codes have RVU values, descriptions, and are recognized by law (thanks to HIPAA), pediatricians still aren't using them.
How are they being used? Well, the 99441 - the lowly "Phone e/m by phys 5-10 min" - makes up nealy 75% of all the usage. Maybe that's normal, but we have only one client (and you know who you are!) who has billed the 98966 (same call, but only by a non-doc). And they have billed only 9 since 1/1/09.
Insert my deep sigh here.
However, here's the good news. We have some new payers who are covering these procedures. They include PHC, Health Assurance, Health New England, Americaid, Alta Bates, Tufts, Aetna, DSHS, CHPW, and others.
Here's what I can tell you:
|Average Charge||Average Payment|
So, we have some odd behavior related to the average reimbursement dropping as the value of the code rises, but it's easily explained: payers understand the 99441 and are working their way up the ladder. Although most payers are in the $3-$10 range for these codes, some are paying $14, $27, and even $35 a pop! Amazing.
Tell me, again, why you aren't using these codes?
More detail about the 96110 tomorrow.
About a year ago, we did a quick run-down on the "non face-to-face"codes, more commonly known as "billing for phone calls." It was both encouraging and sad at the same time. Time foran update.
Things are still sad - it's a small minority of PCC clients using thecodes (5%?). However, the news is not all bad.
We have insurance payments, now, in 13 states - CA, MA, NJ, MD, PA,VT, MI, GA, OH, NY, IL, WA, and KY.
We have some major growth in the non-physician phone codeusage (98966-98968).
Below, I've split the results into two categories - how much was charged/paid when the code is paid and how much is charged/paid overall. Note that there isn't a whole lot use of these codes when it's not being paid.
|Code||Average Charge||Average Payment|
|99441 ($ > 0)||$18.80||$6.69|
|99442 ($ > 0)||$37.33||$17.28|
|99443 ($ > 0)||$55.03||$25.46|
|98966 ($ > 0)||$14.72||$6.95|
|98967 ($ > 0)||$33.75||$7.91|
|98968 ($ > 0)||$35.00||$35.00|
Interesting, certainly, no?
Back to the meeting!
So, you get excited about all the information we're sharing about the non-face-to-face codes (also known as the telephone codes) and you want to put this into action in your office...how do you do it?
Among the issues to consider is how to actually document your encounter. M put together a nice little "phone encounter form" which you can print and hand to the docs to take home with them at night. Many of you use similar forms for their hospital rounds. Here's a freebie you can start with. PDF and XLS versions available.
Share and Enjoy.