Posted by: notdeaddinosaur | May 7, 2011

Creative Semantics

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.


  1. What can you do? Yeah, not a whole lot. One thing comes to mind, though – start directing patients to an extremely grateful insurance agent for a company that deals fairly. (As far as such a thing exists.) They would all love you forever, and you’d have a slightly easier life to boot.

  2. I hate doing it, but I often will tell the patient that their insurer will not pay for both the same visit, and ask them to schedule another appointment for the procedure. It’s stupid, but it’s the rules of the game and I did not make them up. One advantage is that I don’t end up running behind becauseI added on extra unscheduled procedures.

    The whole thing is ridiculous. We should be paid for what we do when we do it.

  3. I just tell ’em they’ll have to come back in for the mole. If it’s a chest cold with the pap I usually just take care of it and bill for the well woman (yeah, you eat it, but it probably costs less than fighting with the rat ba@#ard insurance company). Jeremy, would you please tell us on what planet there exists “an insurance company that deals fairly?” Also bear in mind that most insurance is from employment and if the company is very large an agent won’t help.

  4. I end up eating a lot of costs, too. I have a handful of HMOs that pay me less than it costs to give Hepatitis A and B shot boosters. The initial one usually is given at a well checkup with the vaccine and admin codes not meeting my cost to buy the vaccine but the visit making me a profit. The next boosters are all given at a loss. Ditto on hte moles and other skin concerns. I get notes from plastics and gen surgeons who now see the patient for the mole or equivalent and then schedule a separate procedure time for the procedure. This way they get paid for both. I have started doing theis. Ditto on the the prior auth for MRIs and CTs. Why should my staff work for free, and why should I be responsible for results by phone. I have started making the patients come in for their results, just like the specialists.

  5. Mamadoc, I forgot about most insurance being employer. I’m all out of suggestions, then! I will not be a doctor. 😉

  6. I’m no doc, but my impression is that it’s much simpler here in Soviet Canuckistan – bill the gov’t. The same amount is billed for any length visit with a family doc (so as a patient I’m sometimes asked to come back if I come in with two problems that will take longer than a usual apt slot). But, that’s pretty straightforward compared to the nightmare you’re describing. Why aren’t American docs advocating for single-payer insurance?

  7. You should report the company to your state’s insurance commissioner. Occasionally those rat bastards will get off their butts and help.

  8. I understand they want to collect 2 copays from the patient therefore they want two visits. So just charge for the two separate things and have the patient pay both copays at once. Yes, I’m aware that this is not allowed currently, but it should be. Insurance companies are so inane with their regulations.

    Case in point my daughter is going abroad for 4 months. Try getting 4 months worth of prescription in advance even with a prescription for a year’s worth at a time. Just charge me 4 copays and be done with it. But no. Endless miles of red tape where we likely won’t get the script filled in time OR we pay full price for 4 months worth.

    Huge PIA on both sides.

  9. In a rational world, our professional society would be fighting for us on these issues, but the AAFP is so deeply in bed with the insurers and government agencies that they’ve become part of the problem.

  10. How much do you think it would improve if the Medicare reimbursement structure changed to give primary care physicians and other under-paid specialties what they deserve? My understanding is that the AAFP refused to endorse a recent AMA document defending the current payment system. Do you know more about that?

  11. Alas, in my state the insurance commission is a joke, and a bad one at that. The current director is a former (and probably future, no doubt) trial lawyer.

  12. To further complicate the matter from the consumer side, many plans do not charge a co-pay for preventative or well care visits, so they scour the encounter looking for any codes that could invalidate the wellness of the visit, even if it is coded correctly.

  13. That dino is my issue with class action suits.
    If class actions had the result of changing standards as here, I would be a huge fan of that laudable goal. In reality they are mechanisms for lawyers to reap millions while the class usually gets “coupons” or pennies on the dollar while changing nothing.

  14. What about all the people without health insurance, or who are only insured the arts of the year they have work? People like me? If I break my arm I’m going to be paying with both an arm and a leg!

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