To Bundle or Not to Bundle
As time marches on and managed care plans lose their death grip on Emergency Physician Groups in many parts of the country, they have become smarter at taking your money. Yes, it is true that many groups either are no longer forced to participate with every plan the hospital has signed up with or they now have more flexibility to negotiate their rates. Gone or rendered less powerful are the Physician Hospital Organization and Hospital Managed Care Departments that negotiated the rates on behalf of the emergency physicians. These are good changes because few if any understood the challenges of emergency medicine and even fewer had any idea as to the rates or reimbursement needed by emergency physicians. Now, many of you are on your own to negotiate your own managed care deals. This can be great if you pay attention to the details or lack thereof in the contracts.
To date, I have seen very few managed care contracts that address the issue of bundling separately billable procedures. What this means is that the managed care plan purchases software or programs their claims processing machine to bundle procedures that should be paid separately from the Evaluation and Management code (99281-99291) filed with each emergency department encounter. These programmatic changes to their claims payment system are in my opinion nothing more than a managed care plans carefully calculated effort to withhold payment from physicians, which is a whole other issue that needs to be addressed. I see their withholding of reimbursement that is due physicians no different that a physician group who willfully codes their claims incorrectly to gain additional reimbursement that is not due them. So why do the plans have a double standard for compliance? Follow the Money.
The most common forms of bundling occur with EKG interpretations (93010) and X-Ray interpretations. The plans use terminology such as “inclusive”, “incidental”, or “part of the procedure” to determine that they will not pay these codes in addition to your evaluation and management code. Now, as you might guess, this was not addressed in the contract and you are quite surprised when this begins to happen (assuming you billing vendor notifies you as opposed to writing off the balance). What can you do to rectify the problem?
First, appeal the denied EKG or X-Ray interpretation as CPT does not bundle these or state they are part of the evaluation and management code. Most appeals I have seen are initially denied with some type of form letter; therefore, you must appeal up the ladder and get to someone of decision-making authority. Once you get up the ladder, usually they explain that this is covered in the contract under some terminology like “we agree to abide by the XYZ managed care plans claim adjudication and claims processing procedures and thus will not bill recipients for any balances”. While this may sound reasonable at first and in fact you could be stuck by the terms of the contract, I suggest that you raise a large stink and demand that they pay for services that should not be bundled. The most common resolution I have seen is the plan agreeing to pay you more on your evaluation and management codes as most of their systems are not capable of treating one group differently than others on paying for these codes that their software has uniformly bundled. Although you may win the battle with the plan, most plans will continue to take from other physicians would don't have the knowledge you do. Let's look at an example:
Group “A” files 10,000 EKG interpretations with managed care plan “B” that are denied as included in the E&M service. Group “A” does not appeal the denial. If you plan reimburses 125% of Medicare, Group “A” will lose about $107,000 ($8.55 Medicare reimbursement x 1.25 x 10,000) in reimbursement. As you can see, you can justify the time and effort of the appeal for the financial benefit that is due the group.
In summary, watch review your contracts carefully. Ask the plan to place language that prohibits bundling of procedures that is not consistent with CPT. If they waffle or balk, you know they intend to take advantage of you. At this point, be careful about who you are contracting with. What other surprises might they have for you? Lastly, review your explanation or benefits/remittance advices carefully. These will show you their games and alert you to ways you are losing money.