North Dakota Medicaid and Erectile Dysfunction

There’s a lot of talk, much of it really nasty, about how physicians overcharge patients by providing numerous unneeded services to pad their bills. It’s time to stop using physicians as scapegoats for this country’s obscenely expensive health care. Physician salaries account for 10 percent of this country’s health care costs. Physicians have very little to do with the exorbitant cost of health care in this country.

The Center for Medicare and Medicaid Services (CMS), insurance companies, and the media are trying very hard to ignore the real reasons healthcare in this country costs more than any government should tolerate.

I’ve written before on the absolute insanity of trying to file claims for reimbursement for primary care. For the details of what physicians must do to be reimbursed for the care they provide, please see my earlier post “The Ubiquitous 1500 and it’s Sidekick, the EOB.”

In truth, it’s hard to stay awake reading through the many paragraphs of this post, but the trip will make the traditional journey of the Dark Night of the Soul look like a vacation in Cancun.

For starters, those making the rules should have to walk the walk of trying to get a claim paid—and live off the income of the reimbursement. It would be nice to think the rulemakers cared enough to find out why their attempts to reign in healthcare costs have failed miserably. Perhaps the fact that they have their own agenda, apparently to make all health care providers robots in the scheme to control every iota of dispensing what they, the rulemakers, still call health care, is the problem. Hidden agenda or no, the results are tragic.

More and more primary care physicians are opting out of the existing punitive reimbursement system and opening direct primary care practices. Pamela Weible, in addition to her success in bringing physician suicide to public notice, gives workshops on opting out of the CMS and insurance jungle. She calls her model of primary care “Ideal Medicine.” Physicians for a National Health Care Program have just published Beyond the Affordable Care Act: A Physicians’ Proposal for Single-Payer Health Care Reform. To date, the report has been endorsed by 2,466 other physicians than those involved in the creation of the document as well as medical students and even a few health care businesses.

At the current rate of primary care physicians abandoning what corporate medicine has become, it’s reasonable to suggest, as I did in this previous post,  “Where Have All the Physicians Gone.” Add trying to get paid for the care physicians provide as one more reason to abandon the current ship.

To anyone trying to get a claim paid, it becomes quickly apparent that those responsible for paying the claim will latch on to any excuse possible to deny payment. One look at an Explanation of Benefits (EOB) reveals the “explanation” is in the form of riddles. If a biller recognizes a familiar riddle and understands the reason for the denial, the claim can usually be corrected and resubmitted relatively quickly.

If the biller is unable to solve the riddle, the biller has to call the payer to find out the reason for no payment. It is not uncommon for a claim to be returned unpaid a second or third time for some additional reason not mentioned the first time around. Obviously, physicians are forced to hire an army of people just to dog denied claims and resubmit them.

The diagnoses indicating the reasons for the patient visit are found in Section 21 of the 1500 form. If there is only one reason for the visit, there is likely to be only one diagnosis. However, patients seldom visit a primary care physician with only one problem, especially if they are elderly. In the case of this particular denied claim, four diagnoses were listed. There was no payment at all for the claim, even though the other three diagnoses were managed in this patient visit.

This patient had been seen several times over a period of a five or six months. All previous claims had been paid without incident. Suddenly, the claim comes back with zero payment even though there are several diagnoses—several reasons—for the patient’s visit.

Unable to tell from the EOB why the claim was all of a sudden denied, our biller called North Dakota Medicaid.  She was told that ND Medicaid won’t pay the claim as long as the diagnosis of erectile dysfunction was listed on the 1500.

I’ve seen a lot of strange reasons for denying claims, but this one seemed really bizarre to me.

Note that the EOB says “after 3/1/2016, nonspecific claims won’t be paid.” In the coding biz, there are what are sometimes called “bucket codes.” Codes usually ending with a .9 decimal, and described as “unspecified.” Some payers reduce or deny payments for bucket codes.

There was nothing “unspecified” about this code.

Furthermore, this patient was in the clinic for more than this particular problem. This was not a one-diagnosis-code claim. Still, North Dakota Medicaid would not pay the claim at all as long as the ICD-10 code for erectile dysfunction was listed in the diagnosis section.

To be paid for this claim, our biller had to redo the 1500 and remove the offending code.  This required creating a second 1500, this time in paper form rather than electronic form, and to remove the code the physician considered a valid diagnosis. In addition, our biller was required to send along with the revised paper 1500 form the office visit notes for the patient.

Sooooo…North Dakota Medicaid is now telling physicians what diagnosis codes they must not put on their claim forms if they expect to be paid???

Since North Dakota Medicaid also wanted a copy of the patient encounter notes, I was curious if North Dakota Medicaid would also require that the offending code be removed from the encounter notes, not just the 1500 claim form.

I am happy to report that North Dakota Medicaid did not ask that the offending code be removed from the encounter notes, and the claim was quickly paid.

However, the cost of getting this claim paid far exceeded the reimbursement.   Physicians are required to hire armies of coders and billers to create 1500s which as often as not will need to be revised and resubmitted several times for payment. Indeed, the coding training business appears to be almost as lucrative as the Maintenance of Certification (MOC) business.

Most important point: Not one penny of the cost of getting this claim paid improved this patient’s quality of care.

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