United tells doctors if they're coding for more than their peers

The plan views its coding communication as helpful sharing of information, but some physicians see a subtle attempt to encourage downcoding.

By Tyler Chin — Posted Sept. 12, 2005

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Over the past year, UnitedHealth Group has been increasingly informing primary care physicians that their coding of certain high-intensity evaluation and management services surpasses their peers' average, and that their contracts could be terminated if their coding fails to move in line within three to six months.

Retrospective claims review of physicians' billing by insurers is not new, nor is it limited to United. But physicians can expect to see a lot more of it in the future, said Ray Herschman, national consulting practice leader at Mercer Health and Benefits Consulting in Cleveland.

"In general, the whole area of [physician] performance measurement is the new frontier in medicine. There's no question that it's absolutely where the market is going. It's in three areas, and they are evolving at different speeds. The first one is cost. The second one is in clinical quality, and the third one is in the area of patient experience," Herschman said.

One big driver fueling the activity is that technology enabling plans to measure those areas are improving, Herschman said. Another, he said, is that plans believe there are great variants among physicians in treating the same conditions, and billing similar amounts for doing so.

"Our role is to provide data on variation, to share that information with physicians, to help inform them what the sources of variation are or identify areas to have a dialogue around ... and use that as a basis to support physicians in improvements, as they see fit," said Lewis Sandy, MD, executive vice president for clinical strategies and policy at United, the nation's second-largest private-pay health plan, after WellPoint.

But some doctors have a different view.

United says it is "educating physicians, but I think it's also a subtle intimidation," said David Filipi, MD, a family physician and medical director of a 130-doctor multispecialty group practice in Omaha, Neb.

During the past year, several members of his group were visited by a United representative, who told them they were outliers, Dr. Filipi said. But the plan "quickly backed off" after the group told the payer that it periodically audits charts and teaches its doctors how to code appropriately, Dr. Filipi said. The group also told United that some of the doctors in question treat patients that require more complex decision-making.

"In response to that, they said, 'Well, we just want to give you a heads-up that this is going on. We're just trying to be helpful.' When in fact what I think they are trying to do is have physicians regress more towards the national tendency of undercoding," said Dr. Filipi, chair of the Nebraska Medical Assn.'s Committee on Healthcare Insurance.

Dr. Sandy responded: "Our philosophy relating to E&M coding is that we believe that physicians should do what is necessary to take care of their patients and to properly document the care that's provided, and then to bill appropriately given the care that was rendered."

Pushing back

Doctors identified as coding "outliers" by insurers may indeed be coding accurately and appropriately and should not be cowed into immediately changing how they code, Dr. Filipi and others said.

United advised Earl J. Carstensen, MD, a solo family physician in Aurora, Colo., that his billing of high-intensity E&M codes was at "variance" with his peers' average. In part because United makes up 40% of his business, Dr. Carstensen paid $500 to take a coding course the insurer recommended. His office made it a point to let patients know that he would only treat them for the problem that led them to seek the appointment, Dr. Carstensen said. When patients cited additional non-urgent problems during the visit, he told them they would have to schedule another visit.

In February, United wrote that his coding had improved in one area but not enough in another. This time, Dr. Carstensen reacted differently.

He asked the American Academy of Family Physicians and the Colorado Medical Society for help, including arranging and attending meetings with the insurer. He also started a listserv on AAFP's Web site, asking fellow members for support and suggestions.

About 70 doctors from 27 states joined the listserv. Several of them got their state AAFP chapters to approve resolutions calling on health plans to abide by CPT billing rules and refrain from using arbitrary guidelines to exclude them from networks. It's expected that the AAFP will consider those resolutions at its annual meeting later this month in San Francisco.

In Dr. Carstensen's case, United appears to have backed off, telling him and the AAFP in August that the insurer's priority is to roll out a new initiative on quality and cost in 20 states.

Under the initiative, UnitedHealth Premium Designation, the plan will "designate" or identify physicians in its network whose claims data demonstrates they are high-quality and cost-efficient physicians.

The Premium Designation program is the successor to the UnitedHealth Performance program the insurer tested in St. Louis earlier this year. That program was harshly criticized by several medical societies, including the AMA and the Missouri State Medical Assn., because they felt it measured doctors primarily on their cost effectiveness.

"Health plan profiling of physicians based solely on economic or other flawed data is strongly opposed by the AMA," said AMA Secretary Joseph Heyman, MD. "Physicians are often given limited, if any, information or reasoning from the health plans as to why they are being audited. We are concerned that this profiling does not take into account a physician's specialty, geographic area of practice or the physician's patient population."

To combat this problem, the AMA Private Sector Advocacy offers physicians an online complaint form to report complaints about health plans on a confidential basis.

Whether United's new program will be good for Dr. Carstensen remains to be seen. "I remain unclear about the standards of 'acceptable' primary care physician clinical behavior as defined by United," he said. "I fear that United's standards might be different than mine and my patients'. If this is the case, we return to the same point but in a different way and different name."

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Game plan

If a health plan asks you to defend your coding:

  • Don't be intimidated.
  • Ask a peer or a partner to review your charts, or hire an outside auditing firm.
  • Enlist assistance from your local medical society.
  • Investigate and respond constructively to the health plan, including asking for a meeting to discuss the issue.
  • Have a compliance audit and monitoring program in place that includes coding education and routine chart reviews. If you don't have a compliance audit and monitoring plan, adopt one for your practice.
  • Review a report of physician services and how frequently they have been performed over a one- to six-month period.
  • Obtain the most current Medicare evaluation and management frequency data from your Medicare carrier or fiscal intermediary for your state and nationally for your medical specialty.
  • Review the E&M supporting documentation and indicate why the distribution of your E&M frequency data is different than the Medicare E&M frequency data for peers by specialty and state or appropriate geographically defined area.

Sources: AMA; American Academy of Family Physicians, American Academy of Neurology; David Filipi, MD; Earl J. Carstensen, MD

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External links

Health plan complaint form from the AMA Private Sector Advocacy (link)

AMA and the American Academy of Neurology on how to prepare for a health plan retrospective audit, in pdf, available to AMA members only (link)

AMA and AAN on how practices can perform an internal billing audit, in pdf (link)

"Are You Prepared to Defend Your Coding?" Family Practice Management, June (link)

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