How to get paid for care delivered over the phone

For many physicians, the frustration of the telephone is that they have to spend a lot of time using it, yet they don't get paid.

But it is possible to get paid for your work on the phone. It takes the right coding for the right situations, the right documentation and persistence. It also might require a willingness to bill your patients if insurers will not pay.

"Some payers are agreeing to pay for it," said Penny Noyes, president and CEO of Health Business Navigators in Bowling Green, Ky. "And it should be billed. If you bill, physicians may only get paid about 10% of the time, but if they don't bill it, they get paid 0% of the time."

Most practices provide telephone services without charge, although attempts to reduce phone time may involve cramming even more patients into a packed schedule. This is not necessarily convenient for the patient or best for a medical practice's economic viability.

"A lot of offices are full. If you can talk to a patient by telephone after hours or during the lunch time, that's good for the patient and the practice," said Sharon Bolarakis, a coding compliance auditor and educator with EthosPartners Healthcare Management Group.

Lots of phone consulting

Some research has indicated that 20% or more of the clinical services provided in some specialties are done over the phone. But most of the time spent on the phone with patients cannot be reimbursed, because it is considered part of a face-to-face visit, the call is short, or the insurer doesn't cover it. "These services have very specific guidelines in order to bill for them," said Betsy Nicoletti, author of The Field Guide to Physician Coding.

Insurers increasingly are willing to pay for e-mail consultations, but physicians who deliver care by telephone say voice communication offers better patient care.

"You can get more patient interaction over the telephone," said Andrew Hertz, MD, chair of the American Academy of Pediatrics' Section on Telehealth Care. "There's a role for e-mail, but the communication is more one-sided."

Medicare and many private insurers do not pay for telephone visits. Some third-party payers will pay if the calls are coded properly.

For instance, a billable call can be initiated only by an established patient or the patient's guardian. In addition, the conversation cannot be related to a face-to-face appointment that occurred within the past week or will happen within the next 24 hours or the next earliest available appointment. In other words, the call has to substitute for in-office care.

The relevant codes are:

• 99441: Five to ten minutes of medical discussion.
• 99442: 11 to 20 minutes of medical discussion.
• 99443: 21 to 30 minutes of medical discussion.
• 98966, 98967 and 98968: The comparable codes for care provided by other health professionals.

To increase the likelihood of payment, the call must be documented like an in-person visit, with particular notation of the time spent. In addition, experts advocate spelling out in contracts with insurers that such services will be covered. This doesn't guarantee that calls will be paid for, because an employer may decide not to include that option for employees, but it does make it more likely.

Tracking payment

Once a practice starts billing for telephone care, Noyes suggests tracking which insurers pay and which don't, to determine when such billing is worthwhile.

If an insurer does not cover phone calls, it may be possible to bill patients separately. Most insurers allow patients to be billed for medically necessary noncovered services.

There's always a risk that some patients may switch physicians if a practice implements a policy of charging for extensive telephone calls, but physicians who have made this a part of their practice say this is not a significant problem. Patients can get used to it.

Also, many patients appreciate the convenience of being able to talk to a physician by telephone rather than having to make an appointment in the office.

"Some patients don't want to take three hours off work to go to the doctor. It might be worth it for them," said Margo Williams, who is a senior associate at the American College of Physicians.

Physicians who already bill for telephone services suggest that others who want to start doing this inform patients ahead of time.

"I would make sure that your patient information is clear, such as on the practice Web site, in new-patient communications, and any other patient brochures or signs, that there is a charge for phone calls, what the charge is, and what the parameters are for the charges," Williams said.

Experts also advocate presenting this policy change as a way to save patients time and money.

"Our families are paying it," said Dr. Hertz, medical director of the Rainbow Call Center at the Rainbow Babies and Children's Hospital in Cleveland. "If a patient should be seen, there's not a charge for the telephone call. If they need really significant phone care in place of a visit, we do charge. It's an effective and safe way to provide care."

Even if bills are not sent, experts say it is still important to document in the medical record everything that occurred during a call. Although Medicare will not cover telephone visits, the time spent on them can be taken into account when determining the code level for the next face-to-face visit, according to the Centers for Medicare & Medicaid Services.

Most medical societies, including the American Medical Association, support payment for medically necessary care provided by telephone.