Health Care Reform - Primary Care view

I recently dealt with the governmental affairs leadership and staff at the American Academy of Pediatrics national meeting in Washington. I have found them timid in general. So I have tried, repeatedly and unsuccessfully, to put a burr under their saddles, and words in their mouths. Here is what I wrote up for them for storage in their circular files.

Proposal: Rationalizing Insurance Payments to Practitioners

The weaknesses of the way health insurance companies deal with the public are well known: exclusions for prior conditions, rescissions, exclusions from care, exorbitant costs for individuals, etc. These are being addressed by the current health reform legislation proposals.

Less prominent in discussions have been the difficulties that practitioners have had with health insurance companies. It is well known that insurance companies are very concentrated, while most practitioners, especially in primary care, are diffuse. The power of the insurance companies has thus inhibited negotiations between them and practitioners from being rather equal. Most observers regard many insurance company practices vis-à-vis practitioners as unfair.

One of the most important ways that insurance companies have restricted their payments is by not observing the CPT codes. On the one hand, practitioners are required to obey the strictures of CPT coding to the letter. On the other, insurance companies are not so constrained. In the past they have down-coded payments; private lawsuits have largely stopped this practice. But the insurance companies still maintain the practice of simply not recognizing some of the official codes.

An example would be: for well child exams, the CPT coding manual instructs the practitioner to bill separately for the visit, vision testing, hearing testing, and developmental testing. Many insurance companies, however, refuse to pay for the latter three tests, claiming that these tests are “included under the well child code.” This is directly in violation of the CPT coding instructions.

Another example would be coding for after hours or weekend visits. These codes are well established in the CPT manual. Many insurance companies simply say, “We do not recognize these codes.” Individual practices have sometimes been able to induce the companies to change this practice by pointing out how much money is saved for the company by seeing the patient out of hours, rather than referring the patient to the emergency department at a hospital. But most practices cannot make this negotiation work.

This problem with CPT coding is one component of the elevation of medical care costs. The insurance companies have an army of workers to deal with the practices as they protest non-observation of the CPT coding rules. Another army of clerks is employed by the practices, trying to collect on these claims. This collision of interests winds up being in no one’s interest.

The solution for this problem could be a simple stricture in federal law that insurance companies are required to observe the CPT coding manual and abide by it. As legislation is being prepared to change the ground rules for insurance companies dealing with patients, a parallel change could be effected in how the insurance companies deal with practitioners. While there are no doubt other issues to be addressed in this unequal relationship, surely the CPT coding imbalance should be resolved.

One way might be to insert language into the Health Insurance Exchange portion of the health insurance reform bill. In any case, this problem needs to be addressed, and the time would appear to be now.

Budd Shenkin