Putting Payers' Feet to the Fire

October 4, 2005

Family physicians who have seen correctly coded claims denied are claiming victory. They haven't seen any additional dollars so far, but the AAFP Congress of Delegates voted to take action against payers that reject appropriate claims.

Family physicians who have seen correctly coded claims denied are claiming victory. They haven't seen any additional dollars so far, but the AAFP Congress of Delegates voted to take action against payers that reject appropriate claims.

The Congress vote follows 15 chapter resolutions and heated testimony on claims with a "-25" modifier. Rather than paying for multiple services delivered during a single visit, insurers bundle the services and pay less than the CPT calls for.

"There was a day when we could afford to throw in those services without being compensated," said Steven Bruner, M.D., from Lawrence, KS. "But in light of Medicare and Medicaid cuts, those days are past."

Problems are rife according to testimony presented at the reference committee hearing. Some health plans are threatening to drop family physicians because they are coding higher than other physicians, even though the higher coding is accurate and appropriate. Other family docs are being told to cease and desist with the upcoding because it costs too much, not because it is inaccurate.

Michigan AFP president Peter Scuccimarri, M.D. offered a typical example. The Ann Arbor physician reported seeing two patients with acute cellulitis of the lower left extremity in the past two weeks. One needed hospital care, the other did not.

"For the one not hospitalized, I'll get dinged for the cost of care," Dr. Scuccimarri said. "But who do you think cost the health care system more? This is really common sense, but coding and reimbursement are anything but."

Delegates decided that it is not acceptable for health plans "to threaten to restrict, terminate or exclude a family physician from plan participation based on his or her coding pattern" as long as the physician provides medically necessary services and abides by CPT rules.

Delegates also directed the Academy's delegation to the American Medical Association to work within AMA. The goal is better adherence to the coding guidelines contained in the CPT manual and the CPT license contracts with insurers.

AAFP is also gathering ammunition just in case working within the system doesn't work out. Delegates also voted to create a health plan clearinghouse and asked members to start collecting and contributing their experiences to build a data bank. AAFP leaders will used the data when they discuss issues with employers and health plan leaders. Members will also be able to track denial and approval patterns from plan to plan.