Fair Billing Practices
We practice in a climate of high-deductible, low quality healthcare insurance. Decisions that we make when billing patients can have significant, and sometimes devastating, financial impact on our patients. I have been an eyelid surgeon for the past 9 years in several different practice models (from an academic center to a boutique plastic surgery practice to my current practice), and I have developed strong beliefs on how to fairly manage the financial transactions that go hand-in-hand with medical and surgical services.
There are several facets of eyelid surgery that make it different from many other types of surgeries, from a billing perspective. Eyelid surgery is somewhat unique in that it often requires numerous billing codes, since multiple eyelids are operated on at the same time during the same surgical setting. Eyelid surgery is also unique because the distinction between what is medical and what is cosmetic is sometimes blurred. This leads to some challenges in billing and collection. It also leads to burdensome audits from insurers and from the Centers of Medicare and Medicaid, to insure that cosmetic surgery is not being billed inappropriately to insurers.
As a surgeon, I strive to maintain ethical standards and develop a trust with my patients that is inviolate. I will develop a surgical plan and carry it out on my patients in the same manner that I would for a close friend or family member. I will expect to get compensated for my services, but in a manner that is fair and not exploitative. Below, I will describe the billing practices that I will avoid because I believe they are unfair to patients. I will also discuss some expectations that I have from my patients.
Finally, I have a belief that 90% of all surgeons make ethical billing and patient care decisions. I am highlighting outlying scenarios that I think adversely affect patient finances and outcomes.
Billing Practices that I Choose to Avoid
Plus the Expectations that I Have from Patients:
Some surgical codes reimburse more than others, and the codes that pay more can be chosen. Here is a real world example: Occasionally surgeons are called upon to review charts from other surgeons as a quality control measure in surgical centers. Several years ago I reviewed an operative report that sounded quite invasive. Numerous high-paying codes. However, when I read the text of the operative report and sifted through what was actually done, it was truly a case that I often do in the office in 5 minutes during initial office consultation. Medicare would have paid me $105.51 for the procedure, and more than likely even less than that if done during the initial office setting. The surgeon who upcoded would have expected to collect about $2031.67. The codes chosen in the surgical center literally paid twenty times as much as the codes that were appropriate.
2. Refusal to do bilateral cases in the same surgical setting.
I will not unnecessarily split up procedures solely to increase collections. I will, however, split up surgeries if medically indicated, as follows: I will not perform surgery on right and left side at the same time if it requires both eyes to be sewn closed postoperatively (since the patient won’t be able to function for a week!), and I will split procedures up if I think doing so will make the long-term outcome more predictable or increase the overall rate of success of the procedures.
3. “Sharing” surgeries in a gratuitous manner.
A few years ago, I was contacted by an ENT who wanted to work with me to do tear drain reconstructions together. There are times when these sort of arrangements make a great deal of sense, in terms of efficiency. I could see this benefitting patients if both surgeons had a high volume of these cases, ran multiple surgical rooms, and could leverage each others skills for high quality, efficient outcomes. However, this sort of arrangement makes NO financial sense for low volume surgeons unless there is fraudulent billing involved. The reason is that the only sensible billing code to use for the ophthalmologist to use pays next to nothing, so why would the surgeon participate in this, unless the billing was creative? Finally, I find that patients who are involved in this sort of care somehow always end up having numerous sinus and lacrimal problems that need to be corrected. I am skeptical that these problems truly exist, instead being conveniently documented for billing purposes.
4. Performing unnecessary surgery.
5. Maximizing profit by only performing surgery outside of the global postoperative period.
Most major surgeries have a 90 day “global period”. That means that all care related to the underlying disorder, within 90 days of the surgery, is not billable. It is possible to bill more if a follow-up surgery is spaced out 91 days from a preceding procedure. I will do this under limited conditions, for example, when the healing period of the primary surgery justifies waiting 90 days for a secondary surgery, or if the patient understands that their initial procedure is exceedingly complex, or if we discussed preoperatively that the initial surgery carries a high reoperation rate.
I try to schedule postoperative office visits within the 90 day global period so that patients do not get billed again after their surgery. For this reason, my standard upper lid postoperative visits occur at 1 week and 2 months after surgery. If for some reason the visit falls beyond the 90 day period, I absolutely do bill patients for those visits. In fact, I have to: Medicare requires that I bill all patients the same.
6. Making tons of money on revisions.
The most common surgery that I perform is upper lid ptosis repair. This procedure involves lifting the lids so that patients can see better. There is about a 10% revision rate with this surgery, and try as it might, that’s about what it is. I don’t charge patients for those revisions, even if it is outside the global period. These patients can almost always have their revisions in the office, so that they do not occur additional facility expenses as well.
Here is a scenario that troubles me: Imagine that a surgeon performs a cosmetic surgery and it doesn’t go well. Let’s say this patient needs multiple revisions. The surgeon, if he or she owns their own surgical center, can book that surgery 91 days after the original and bill insurance. They can tell the patient “I am going to work with you, I will only take what insurance pays.” This may sound like a very generous thing to do, but in reality, it is a cash cow. The surgeon collects money on the facility side from insurance, and collects whatever the insurance pays, and does this for each revisional surgery. In essence, this surgeon has gotten paid to create a surgical problem initially, then bills insurance numerous times to try to fix it.
Every surgeon has revisions. I certainly do as well. It is unusual that my revision would require sedation, and therefore, it is unusual that it could not be completed in the office at no charge. Perhaps 2-3 times per year I have a patient that needs sedation for a revision. If the case is cosmetic, I don’t charge them, and I cover the facility expense myself. If the case is insurance initially, I do believe it is appropriate to bill their insurance for revision requiring sedation, at least for the facility expense. I generally do not bill for my own surgery in those instances.
7. Spreading out care over multiple visits when it could be done immediately.
Lets look at the economics of this decision. If a surgeon schedules a procedure that costs $250, they collect the full amount if done on separate visits, but only 75% of the amount if done during the initial office visit. Thus, surgeons have financial incentive to spread care out over numerous visits.
8. Scheduling surgery in a surgical center for minor procedures that could be done in the office setting during the initial visit.
The Other Side of the Coin: Expectations that I Have from Patients:
I will absolutely bill patients for services if the claim gets denied. Of course, I will go through formal appeals processes to the full extent possible, prior to sending a bill to patients. For patients with commercial insurance that are “borderline”, I submit them for prior authorization by the insurance company. A few times a year, the “prior authorized” cases get denied after surgery. Yes, you read that right. In these instances, I absolutely do bill those patients with whom I have had an up-front discussion about their financial risk prior to undergoing surgery.
I make all patients who are undergoing eyelid surgery sign an “advanced beneficiary notice”, or “ABN.” This states how much I am going to bill them if their insurance denies their claim. This is important, because Medicare does not “prior authorize” procedures: they rely on me to verify that the patient’s condition meets their local criteria for care. (This is why going to a plastic surgeon, versus an oculoplastic surgeon, for an insurance blepharoplasty, is a dicey proposition — they are less capable of making this assessment.)
I will do my best to prevent any financial surprises for patients. But occasionally patients are disappointed with their insurance company, or with Medicare. I cannot control that.
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Dr. Walrath serves patients in Atlanta (Sandy Springs), Cumming, Lawrenceville, Gainesville, Covington, and Stockbridge. He performs minor office procedures in all locations. Major surgical procedures are performed in Atlanta, Alpharetta, Cumming, Gainesville, and Covington.
JOSEPH WALRATH MD
800 Mt. Vernon Hwy NE, Suite 120
Atlanta, GA 30328
Mon-Fri: 8:00am - 5:00pm
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