Tuesday, October 7, 2008

The Sherpa's Plan: Fraudulent Acts for 200 Bucks. Enter the Nurse Geneticist!!

There is a storm coming. The way clinical genetics services are delivered in academic centers needs to change. Trying to make money through incident services could costs counselors and genetics departments everywhere.

Billing through an extender leverages the already busy clinician and helps us see many patients.

When a physician needs to bill for an extender they pick an NP or a PA. If they pick a CGC and never see the patient, bill for a clinical consult, and have someone forge their name, then they could be in a little bit of trouble. Especially with Medicare.....

Yet that is precisely what is happening in a majority of medical centers in the country. In my unscientific poll, 15 of the top 30 institutions who host cancer genetics clinics are doing this exact thing. I won't point fingers anywhere, but Friends....this is insurance fraud.

How is that so?

Well, according to the CPT code 99245, which 20 of the top 30 do code for and bill insurance for must include....

Outpatient Consultation: CPT Code 99245
Key Components (All 3 meet or exceed requirements)
E/M Comprehensive History
E/M Comprehensive Exam
E/M High Complexity Medical Decision
Problem Severity
E/M Moderate Severity Problem
E/M High Severity Problem
Physician Time: 80 minutes

When I asked several patients referred and seen at several cancer genetics clinics in New England, only 10% said they were seen by the medical director of the clinic. 20% think they were seen by a doctor, but upon review it was a very disappointing 12% that ever were seen by an MD. Yet, a quick review of their EOBs stated that they received a 99245......

That is called insurance fraud in many instances. I wonder what the insurers would say if this cat were outta the bag?

This all could be solved if:

1. The physician saw the patient and did the majority of the work

2. A physician extender who can perform a physical exam does the majority of the work

3. They don't bill insurance and take only fee for service

4. They don't bill for a 99245 and instead use the genetic counseling CPT code 96040 with HCPCS S0265: Genetic counseling, under physician supervision, each 15 minutes

Why isn't this happening? Because in a recent AJHG review . ....

Average reimbursement for 96040 was $53.87.

In the small number of instances where multiple submissions of 96040 were made because of a prolonged GC visit, payment for each submission was the same. Mean reimbursement for other E&M services were:





99245-$249.38.....(Man, my attorney makes 200 USD more per hour and he doesn't do nearly as much for my health!)

Willing to commit Insurance Fraud for 200 bucks per case? A resounding Yes!

My Friends, this is a non-sustainable situation. As soon as some insurers get wind of this (Trust me they already have) you will find fines and lawsuits galore. But I have a solution, the answer.....Nurse Geneticists. You see, nurses can be billed as physician extenders, legally. In some states doing this for CGCs is allowed....but that may change, given Medicare's reluctance.

“Incident to” billing enables certain categories of non-physician health care providers to bill through a supervising physician. Medicare permits this type of billing for the following non-physician practitioners: Clinical Psychologists, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, Nurse Midwives, and Certified Registered Nurse Anesthetists. Genetic Counselors are not included most of the time.

Nurses can perform exams....and NPs can do this on their own. PAs can also bill through physicians. This enables you to bill at a sustainable rate for services.

How can you help us accelerate this movement? Call your insurer. Demand to be seen by a physician or physician extender if you were going to be billed for a 99245. How would you know? Check your EOB (explanation of benefits). My geneticist friends will be having strokes now. Why? They are too busy in the lab or writing grant proposals to see patients.

"Especially the "Bread and Butter" BRCAs that the counselors see" unquote. Personally, I find it insulting to counselors to talk that way. They deserve clinical counterparts to collaborate with them. They are not your workhorse!
Secondly, there are many patients out there who could use a good physical exam to enhance their cancer work up. Why isn't this getting done? Because Clinical Genetics Departments sit inside basic science departments and the focus is on discovery. Not clinical care....why? I think I just showed you the CPT reason why. 250 a patient? I charge 750 per visit just to stay afloat!

Why should you demand this service? It will put stress on the broken system. To repair that system, we must first rebuild the foundation.

The Genetics Education Program for Nurses at Cincinatti Childrens is doing just that. Nurses are the foundation of great clinical care. Why shouldn't they be a part of Genomic Medicine?

From their site:

The Cincinnati Children's Hospital Medical Center's Genetics Program for Nursing Faculty (GPNF) was a multifaceted genetics educational program for nursing faculty. The GPNF was made possible through funding from the Ethical, Legal, and Social Implications Research Program of the National Human Genome Research Institute at the National Institutes of Health and the Division of Nursing, Health Resources and Services Administration.
The GPNF highly acclaimed offerings consisted of:

Seven annual on-site Genetics Summer Institutes (GSIs)
Web-Based Genetics Institute (WBGI)
Participant follow-up, educational support, and networking opportunities
A two-day genetics update workshop offered every two years

Nurses have existed on the fringe in this field. I am certain their day is coming. ISONG does too.

What is ISONG? The International Society of Nurses in Genetics. They are committed to working with genetic counselors. I think this is the right way to go. Unfortunately, many departments view one or the other as an extra cost. That is, until now. You see, if the departments can get away with 99245 without physician exam, then they won't staff appropriately. If they don't have to staff appropriately, they never get the collaboration which is needed here. They are too short sighted to see......

The Sherpa Says:

Legal loopholes may let your department survive with this "billing scheme" for now. But it will change very soon and someone will get fined or punished. I hope your academic center is ready to truly support the clinical department.


Anonymous said...

I have an idea, but I don't know if it would be useful at all.

For patients that are hospitalized, they could have a mandatory family history done. I'm not refering to patients who have an ortho type of surgery done, but the patients who are in for heart disease, stroke, cancer, or for unknown reasons.

A person could go from room to room (1 person in charge of each floor), and do the family history.

In the clinical setting, all of that time spent waiting for the doctor could be used to do a detailed family history. So schedule an appointment time for a family history before the doctor sees the patient. So each department should have 1 or two people on staff (the number of people that would be needed for each department would vary..obviously) that could do the family history.

Like I said, I don't know if this would even be useful.

Anonymous said...

I am very dissapointed about "The Sherpa Plan" You should be advocating for genetic counselors to be better reimbursed and those providers to be recognized for their training and very specific expertise. What you are proposing will actually hurt patients, the medical system and the personalized medicine effort altogether. Advocate for genetic counselors to be recognized by insurance payors and more appropriately reimbursed. This will attract more into this highly specialized field, more hospitals will hire genetic counselors and then the billing can be done legally. Please note that insurance companied are well aware of billing practices for genetic counselors. Our institition submitted a bill to a major payor using 96040. When it was declined, the rep at the insruance company told the patient to call the genetic counselor and see if she would consider submitting the claim using 96040 (because that is what supposedly genetic counselors do per that Rep). We explained to the patient that this would be fraud. Please note that the clain was NOT paid using 96040. Therefore, please use your time and energy wisely, advocate for genetic counselors. They are the gatekeepers to responsible genetic information.