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Creative Semantics Used By Health Insurance Companies To Avoid Payments

Insurance companies are supposed to pay for health care, although they do everything they can think of to avoid doing so. One company in particular (a small player here though a much bigger gorilla in other markets) does so by playing with words, even when another behemoth lost a lawsuit over the same issue.

The topic involves paying for preventive services while a patient is in the office for care of an acute illness or management of a chronic condition. The way we communicate with insurance companies about what we do in the office is by way of codes; CPT codes, to be precise. There are separate codes to differentiate between preventive services and the so-called Evaluation and Management (E/M) services. The latter are your basic office visit codes covering all the “cognitive” services I offer — as opposed to procedural codes, where I actually do something to you other than talk with and examine you.

In general, you can only have one office visit per day. However if you happen to ask me to take a mole off while you’re in for a diabetes check, or if I find that you’re wheezing when you just came in for a checkup, there is a way to code for more than one appropriate service at a time by using something called the -25 modifier.

The -25 modifier is added to the E/M code to indicate that the evaluation service was completely separate from the procedural one. That is, the diabetes exam had nothing to do with the mole, or the asthma was completely separate from the Boy Scout physical. For a long time, many insurance companies refused to pay for an E/M code in addition to a preventive visit. Here for a pap but came down with a chest cold? Sorry; you have to choose which one you want me to take care of today, because although they really are completely separate services, I can’t get paid for both.

Then this little insurance company, call them “Company A”, lost a class action lawsuit over just this issue, and had to pay out big time. You’d think others might have taken notice; sadly, not. What’s infuriating, though, is how they now play with words to avoid paying.

Here’s how it works: their provider relations people tell me on the phone that preventive services are “well visits”. By this semantic equivalence, evaluation and management services — all other visits for acute illness or chronic disease — are “sick visits”. And of course, how can you be “sick” and “well” at the same time? Mutually exclusive, you see.

False, wrong, and illegal as hell. But what realistic recourse do I have? Other than dropping that plan — and inconveniencing/alienating a chunk of patients — none. Sometimes it sucks to be small.

*This blog post was originally published at Musings of a Dinosaur*

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