Sent a threatening letter from a company for too many 99214

[MedMan80]

Recently got a letter from a third party company (don't recall the name), comparing my billing codes with others of the same specialty. While it was worded as nicely as possible it indicated that i was billing more 99214 and less 99213 than the average joe psychiatrist. It also suggested I could be audited if this trend continues, it did not specify any insurance companies. I work in a rural hospital and see the sickest of the sick kids, comorbidity is the rule. I'm not concerned my notes won't hold up to scrutiny, but something like this definitely wants me to look at cash only or cash plus 1-2 insurances for future opportunities. Anyone else see such letters?

---

Members don't see this ad.

 

[deleted1100659]

Any incentive to bill 99214? Are you RVU based or production bonus of some sorts? I have never dealt with this sort of thing, that is weird they don't even list the insurance company. Is there a callback number or something? I wonder what average they're even comparing it to considering like you said, you're in a rural setting, so comparing it to a high income city would be fruitless. Im also in higher acuity area, so most of mine would easily meet criteria for 99214.

 

[VA Hopeful Dr]

Recently got a letter from a third party company (don't recall the name), comparing my billing codes with others of the same specialty. While it was worded as nicely as possible it indicated that i was billing more 99214 and less 99213 than the average joe psychiatrist. It also suggested I could be audited if this trend continues, it did not specify any insurance companies. I work in a rural hospital and see the sickest of the sick kids, comorbidity is the rule. I'm not concerned my notes won't hold up to scrutiny, but something like this definitely wants me to look at cash only or cash plus 1-2 insurances for future opportunities. Anyone else see such letters?

We see this sort of thing in primary care every so often. If you're convinced you'll do fine in an audit, ignore the letter. If they do audit and find nothing, you were obviously fine.

This is mostly them trying to bully you into under-coding.

 

[wolfvgang22]

I'm confused. If it's not from CMS, or an insurance plan you take, or from your employer, why would you care what some random company thinks if you know you are billing correctly? This sounds like spam or scam mail.

 

[deleted1100659]

I'm confused. If it's not from CMS, or an insurance plan you take, or from your employer, why would you care what some random company thinks if you know you are billing correctly? This sounds like spam or scam mail.

Thats what I wondered- don't they have to disclose what company they're from? Seems incredibly sketchy that they don't even say who its from.

edit- misread and saw they did tell you company name and it was a random third party

 

[WisNeuro]

We see this for some of our codes here and there, especially some of the therapy codes. In general, may be a good time to review your documentation to make sure that if you do get audited, it's clear why that code was billed in that instance. Back at the hospital, our docs would get dinged for similar things, and because their documentation sucked, the payer can claw back some of that reimbursement.

 

[Sushirolls]

I've gotten it twice, possibly thrice. Sent by two different insurance companies.

I believe it comes from ChangeHealthcare, which oddly enough was bought out by UHC/Optum. So interesting that the contracts other insurance companies have with them is probably just gifting their internal data of claims to UHC...

I'm now at the point where I won't change what I'm doing after doing the mental review of coding but should I get audited - it'll like be my prompt to go cash only. I fear these third party entities are incentivized to find things which gets them a cut of the claw back. So things that would be gray areas, or not even gray areas, they simply say was coded wrong to make them look better and get bigger percentage - similar to a Rack Audit. Then it behooves us to figure out is it worth the fight to contest?

Thankfully, we're Psych, so probably not worth the fight to contest but simply use it as source of inspiration to just go cash only.

 

[AD04]

Isn't there internal auditing done at the hospital? If your documentation for billing codes is lacking, they should inform you.

A lot of the people who document well and know how to bill largely code 99214s for follow ups.

If you ever get audited and lose, there is a silver lining that you can learn from the situation and improve.

 

[WisNeuro]

Isn't there internal auditing done at the hospital? If your documentation for billing codes is lacking, they should inform you.

A lot of the people who document well and know how to bill largely code 99214s for follow ups.

If you ever get audited and lose, there is a silver lining that you can learn from the situation and improve.

There should be. We unfortunately had a great deal of turnover in a certain time frame and some things fell off, we then had to do some training of the coding specialists along with providers to fix a couple things. In hindsight, may have contributed to our hospital losing high 7 figures a year.

 

[MedMan80]

Isn't there internal auditing done at the hospital? If your documentation for billing codes is lacking, they should inform you.

A lot of the people who document well and know how to bill largely code 99214s for follow ups.

If you ever get audited and lose, there is a silver lining that you can learn from the situation and improve.

Absolutely there is, when they did it for me recently i was at 90% compliance. Although i find our billing department lackluster, they will deal with the brunt of the audit should it come. I do see this as bullying at the end of the day and i think it'll drive more of us to go to cash. And yes i can confirm it was from Change Healthcare.

 

[MedMan80]

I'm confused. If it's not from CMS, or an insurance plan you take, or from your employer, why would you care what some random company thinks if you know you are billing correctly? This sounds like spam or scam mail.

They accurately had the distribution of my billing, someone above clarified that it was using a company bought out by UHS although no mention of them anywhere in the letter.

 

[Dharma]

Time for more 99215's!

If you're documenting well and hitting the requirements for the 99214, then it's TFB for said third party. High complexity patients call for high complexity documentation and billing.

 

[PsyDr]

Forward it to your state's department of insurance, and ask them if this is okay.

 

[splik]

Yup, I got one of these letters as well. I have heard of a lot of shrinks getting these letters recently. Must be a new thing. Ignore it. Just make sure your documentation supports the LOS. Unfortunately, many psychiatrists do not document sufficiently for 99214 even though most visits would meet this level.

 

[calvnandhobbs68]

Anyone can be audited at any time for any reason. It's in your insurance contract even, they don't even have to give you the warning of saying you're billing too many 99214s. So just support your level of coding and if your documentation supports it, who cares? It's the docs that write like "patient stable, no new complaints, no med changes" for their progress note and then bill 4x 99214s an hour that get burned. At a bare minimum under current coding guidelines a 30 minute followup is a 99214.

I got this letter from an insurance company once when I was doing outpatient moonlighting as a resident and tossed it in the shredder. It was like "you're billing 90% 99214s when everyone else is billing 50%"....while I was seeing mostly suboxone patients who had like 4+ problems each lol. Tell em to go suck it.

The vast majority of the times this is a scare tactic. I've said this before but think about if have an algorithm that identifies a certain percentage of 99214s, they send these letters to 1000 doctors and even 1 of them gets scared and downcodes 50% of their encounters to 99213s just to "avoid an audit". They just made their money back. Only benefits the insurance company.

 

[wolfvgang22]

Working in the VA, I have to do so many screening checklists for every little thing, on top of having a lot of high acuity patients. I bill 99214 almost all the time. I should probably bill 99215 more but I've been told a lot of 99215s increase risk of an audit. Too many 99213s make administrators think I'm not working, and would be inaccurate, anyway. It stinks all around.

 

[MedMan80]

Working in the VA, I have to do so many screening checklists for every little thing, on top of having a lot of high acuity patients. I bill 99214 almost all the time. I should probably bill 99215 more but I've been told a lot of 99215s increase risk of an audit. Too many 99213s make administrators think I'm not working, and would be inaccurate, anyway. It stinks all around.

I miss the days of doing a million "suicide risk assessments a day"

 

[romanticscience]

I got this too. My 99214/99213 was reasonably balanced but apparently I’m suppose to be billing at least some as 99212?! Who does that?

I’m afraid these averages are skewed by those who don’t know the rules and just throw 99213 on everything, to be safe.

 

[calvnandhobbs68]

Any incentive to bill 99214? Are you RVU based or production bonus of some sorts? I have never dealt with this sort of thing, that is weird they don't even list the insurance company. Is there a callback number or something? I wonder what average they're even comparing it to considering like you said, you're in a rural setting, so comparing it to a high income city would be fruitless. Im also in higher acuity area, so most of mine would easily meet criteria for 99214.

I got this too. My 99214/99213 was reasonably balanced but apparently I’m suppose to be billing at least some as 99212?! Who does that?

I’m afraid these averages are skewed by those who don’t know the rules and just throw 99213 on everything, to be safe.

They can literally make up whatever they want...they've just figured this is a way to freak doctors out into downcoding.

Like they could throw out any “distribution” of codes possible and how would anyone be able to verify it.

I’ve never billed a 99212…that’s like come into the pcp for contact dermatitis and they tell you the rash will probably go away by itself in a few days. A 99212 should be literally a <5 minute visit. However, I’ve seen on the Facebook groups some people arguing that they bill 99212s+ therapy codes every visit when they see people for psychodynamic therapy multiple times a week…instead of billing the psychoanalysis code. Because it pays more. Which is billing fraud basically. So maybe that’s where that’s coming from.

 

[PikminOC]

Uhc got in trouble for not paying claims. They were successfully sued. So now they just ask everyone for notes and make it a burden that not everyone will jump so they don't have to pay.

 

[nexus73]

What does an automated letter cost? $1. Maybe. If each doctor that gets a letter gets nervous and codes just one 99213 instead of 99214 they’ve made that dollar back many times over. Now imagine 2 or 3 or 50% down coded…that’s a lot of money for a $1 letter. it would be nice if you could send a letter threatening an insurance executives livelihood like that. Those letters actually make me angry and they get filed in the circular bin as soon as I get them. I almost wonder if I subconsciously start billing some 99215s in response. I’ll never know.

 

[MedMan80]

What does an automated letter cost? $1. Maybe. If each doctor that gets a letter gets nervous and codes just one 99213 instead of 99214 they’ve made that dollar back many times over. Now imagine 2 or 3 or 50% down coded…that’s a lot of money for a $1 letter. it would be nice if you could send a letter threatening an insurance executives livelihood like that. Those letters actually make me angry and they get filed in the circular bin as soon as I get them. I almost wonder if I subconsciously start billing some 99215s in response. I’ll never know.

The letter didn't really worry me being hospital employed, I know i'll have help for an audit if the time comes. The solo/busy practitioner can be crushed by one though. And insurance companies cry when they can't find psychiatrists to get on their panels....

 

[Monocles]

If you can justify the 99214s you'll likely have zero issues w/ an audit. I see this as nothing more than empty threats. They can (politely) go pound sand.

 

[AtlasCarraway]

If you can justify the 99214s you'll likely have zero issues w/ an audit. I see this as nothing more than empty threats. They can (politely) go pound sand.

This, but minus the politeness.

This is bullying with no legal repercussions for the insurance company. Criminals.

 

[Mass Effect]

This, but minus the politeness.

This is bullying with no legal repercussions for the insurance company. Criminals.

I'd love to draft a letter back to them saying their letter went in the trash and if they write again, to be sure to CC my attorney who may want to speak with them about harassment. I'd gear up for an audit for sure after that though.

 

[Ironspy]

I wonder what would happen if these letters were forwarded to your attorney general

 

[comp1]

These sort of letters should be illegal. It IS threatening and it's designed to lead you to fraudulently downcode.

 

[Mad Jack]

If the documentation supports the coding then you've got nothing to worry about. Current standards make billing a 99214 in psych *easy* and a lot of people are probably underbilling if anything

 

[Monocles]

Related: OP this is you

 

[MedMan80]

Related: OP this is you

View attachment 343736

more like 99214+90833

 

[hallowmann]

I’ve never billed a 99212…that’s like come into the pcp for contact dermatitis and they tell you the rash will probably go away by itself in a few days.

Nope. That visit is easily a 99213. 99212s are like RN visits. No physician should be billing 99212 for an actual encounter with a patient. Walking in and asking what's going on, looking at the skin, and making the medical decision to prescribe or not is sufficient to justify 99213.

 

[calvnandhobbs68]

Nope. That visit is easily a 99213. 99212s are like RN visits. No physician should be billing 99212 for an actual encounter with a patient. Walking in and asking what's going on, looking at the skin, and making the medical decision to prescribe or not is sufficient to justify 99213.

99212s aren't RN visits. That would be billing fraud.

A 99212 is either a 10 minute visit or addressing 1 self limited/minor problem AND a minimal level of risk. Which is what a visit for contact dermatitis would be unless you're actually prescribing something to address it (then implying that the problem is not self limited). Which would probably then raise it to a 99213. The "medical decision to prescribe or not" is NOT sufficient to justify a 99213 if it's clear the problem will be self limited.

 

[hallowmann]

99212s aren't RN visits. That would be billing fraud.

A 99212 is either a 10 minute visit or addressing 1 self limited/minor problem AND a minimal level of risk. Which is what a visit for contact dermatitis would be unless you're actually prescribing something to address it (then implying that the problem is not self limited). Which would probably then raise it to a 99213. The "medical decision to prescribe or not" is NOT sufficient to justify a 99213 if it's clear the problem will be self limited.

You are correct, I misspoke, 99211 is an RN visit. I suppose I've never actually seen a 99212 visit before. I would typically prescribe something for contact dermatitis and the time it would take for rooming, hearing the history, writing the note, would almost always either exceed timing necessary or there would invariably always be something else, e.g. flu shot, form, reflux, etc. to justify a 99213.

 

[tr]

Almost everything is 99214 with the 2021 changes. Any patient who has at least 2 psych diagnoses qualifies for 99214 even if they're totally stable and it's just a refill visit. Additionally, a patient with 1 psych dx qualifies for 99214 if they have at least one side effect or any change to their regimen is made.
So the only 99213s are stable patients with a single diagnosis who report no side effects and have no changes made. That's a small minority.

 

[allantois]

Nope. That visit is easily a 99213. 99212s are like RN visits. No physician should be billing 99212 for an actual encounter with a patient. Walking in and asking what's going on, looking at the skin, and making the medical decision to prescribe or not is sufficient to justify 99213.

When I was on accutane, my dermatologist would always bill 99212...
I guess if you are in primary care you can always throw in something else to make it a 99213 as you said

 

[VA Hopeful Dr]

When I was on accutane, my dermatologist would always bill 99212...
I guess if you are in primary care you can always throw in something else to make it a 99213 as you said

Your dermatologist was doing it wrong. Given how high risk accutane is that's a slam dunk 99214.

 

[calvnandhobbs68]

Your dermatologist was doing it wrong. Given how high risk accutane is that's a slam dunk 99214.

for real.

I’m guessing with how much money they probably were making probably didn’t care and would rather bill 6x 99212s an hour and be able to write 1 line for the note rather than trying to document enough to hit a 99214, especially under the old rules (where you had to have a certain number of vitals, x parts of a physical exam, etc).

Although you’d think they’d do at least 99213, documentation for that was pretty minimal too. When I went to derm who walked in the room for 5 minutes with her scribe and said “nah that mole looks good” I definitely got hit with a 99213 lol

 

[allantois]

for real.

I’m guessing with how much money they probably were making probably didn’t care and would rather bill 6x 99212s an hour and be able to write 1 line for the note rather than trying to document enough to hit a 99214, especially under the old rules (where you had to have a certain number of vitals, x parts of a physical exam, etc).

Although you’d think they’d do at least 99213, documentation for that was pretty minimal too. When I went to derm who walked in the room for 5 minutes with her scribe and said “nah that mole looks good” I definitely got hit with a 99213 lol

The vitals requirement is interesting since no dermatologist I’ve ever been to ever took vitals

 

[calvnandhobbs68]

The vitals requirement is interesting since no dermatologist I’ve ever been to ever took vitals

yeah the old e+m requirements had specific vitals/exam requirements for each level of service, IF you didn’t fulfill the other 2/3 sections but I find it highly unlikely derm was going to have a fleshed out “history” portion lol

This is the old 99214 requirements for example:

How to Get All the 99214s You Deserve

It’s easier than you might think to get what’s coming to you. [FPM Classics issue.]

www.aafp.org

 

[VA Hopeful Dr]

for real.

I’m guessing with how much money they probably were making probably didn’t care and would rather bill 6x 99212s an hour and be able to write 1 line for the note rather than trying to document enough to hit a 99214, especially under the old rules (where you had to have a certain number of vitals, x parts of a physical exam, etc).

Although you’d think they’d do at least 99213, documentation for that was pretty minimal too. When I went to derm who walked in the room for 5 minutes with her scribe and said “nah that mole looks good” I definitely got hit with a 99213 lol

This was especially true pre-EMR. The FPs in this area saw encounters/day drop with no change in income when they went live with EMR since their coding improved.

 

[Therapist4Chnge]

I'm confused. If it's not from CMS, or an insurance plan you take, or from your employer, why would you care what some random company thinks if you know you are billing correctly? This sounds like spam or scam mail.

Insurance companies often hire TPOs who then "audit" clinicians "randomly". It usually is legal, but it's a scumbag thing to do bc they try and claw back as much as possible. It causes the targeted, and I do mean targeted, practice a ton of extra work to justify the coding. They'll claim it is an "administrative" review or something similar, but it's just an excuse to claw $$ back by arguing about coding.

I dealt w a particularly evil TPO years ago that claimed it was to review administrative billing stuff by pulling "random" cases...yet they chose every single full eval I did, while ignoring follow-up notes and small stuff. They attempted to bully me and claw back mid 5-figures. I went through my state org with mixed results. I then filed a formal complaint w the state's insurance board, which I highly recommend doing if there is even a remote hint of shenanigans. Insurance companies typically fear insurance boards bc they can boot insurance companies from conducting any biz in the state.

I was fortunate that I knew the right people, and with a couple of well-placed phone calls and a receptive insurance board, I got the entire "not calling it a post-payment audit" shutdown, statewide.

Oh ..the TPO that appeared out of thin air just happened to be connected to the insurance company once I followed the paper trail, go figure....right?

 

[Sushirolls]

ChangeHealthcare, the company that has sent some of these letters - unless others got different ones from different organizations? Is picking up some bad press in the past year:

Lawsuits challenge UnitedHealth’s $13B deal with Change Healthcare, while shareholders give OK

Those filing suit claim the radiology vendor has made misleading or incomplete statements about the merger, which Change denies.

www.radiologybusiness.com

APCI: Feds Should Stop UHG's Proposed Acquisition of Change Healthcare

United Health Group's acquisition of Change Healthcare will likely harm competition and lead to increased prescription drug prices and poorer patient outcomes, according to a letter from American Pharmacy Cooperative,

www.benzinga.com

 

[milesed]

99% of mine are 99214- I mange meds and most have 2 or more issues being treated. I have not gotten a letter yet.

 

[calvnandhobbs68]

I also see the reasons why 99213 numbers are artificially inflated when I get records. For instance, someone who basically lines up 15 min med checks and bills them all as 99213s based on time so he can write whatever he wants in the note and not have to worry about it. So yes, technically the panel is I'm sure filled with 24+ 99213s a day they see every month or two. These are patients with absolutely multiple problems that qualify as 99214s no problem that just keep getting meds tossed at them with limited information about why they're getting these meds tossed at them.

Again insurance companies trying to punish you for other people's (intentional?) underbilling.

 

[Sushirolls]

I just got another one from Change Healthcare. I think this is my 4th. This time they actually had 2 pages, for graphs, one for routine E&M and another for telemedicine E&M.

Just a matter of time before they start requesting records, fishing for something, anything.

 

[calvnandhobbs68]

I just got another one from Change Healthcare. I think this is my 4th. This time they actually had 2 pages, for graphs, one for routine E&M and another for telemedicine E&M.

Just a matter of time before they start requesting records, fishing for something, anything.

fancy, wonder how much per hour they charged to put that fancy little graph together? But hey, while they're at it they can go shove those pretty pictures where the sun don't shine.

 

[nexus73]

Would the state insurance commissioner do anything in response to these letters? I think on the surface it seems like the insurance company is just sharing data. But I'd argue the data is probably inaccurate for the reasons noted above (doctors afraid of over-coding so they actually undercode, or employed docs just undercoding because they get no benefit and all risk if they try to code correctly and accidentally over code). Is insurance actually reviewing all notes to make sure they are correctly coded? Doubtful. I'm pretty sure if a complaint goes to the insurance commissioner the insurance company has to deal with it, just like board complaints for docs. It's one way to push back on what I'd say is an unfair business practice.

 

[calvnandhobbs68]

Would the state insurance commissioner do anything in response to these letters? I think on the surface it seems like the insurance company is just sharing data. But I'd argue the data is probably inaccurate for the reasons noted above (doctors afraid of over-coding so they actually undercode, or employed docs just undercoding because they get no benefit and all risk if they try to code correctly and accidentally over code). Is insurance actually reviewing all notes to make sure they are correctly coded? Doubtful. I'm pretty sure if a complaint goes to the insurance commissioner the insurance company has to deal with it, just like board complaints for docs. It's one way to push back on what I'd say is an unfair business practice.

You don't want them reviewing all the notes though...that's an audit. When charges are submitted, insurance companies don't get the notes to review plus the charges, they just get the submitted charges. So submitting all the notes as well for manual review is a huge pain on your end.

What they need to be doing is just not submitting these letters at all and actually randomly auditing people or auditing actual suspicious billing practices but what's most profitable for them to do is try to scare doctors into downcoding with these letters and auditing the doctors that are billing them the most.

 

[MedMan80]

Just got another one from change healthcare, written more politely but again reiterating an audit if billing practices continue. I welcome it!

 

[Sushirolls]

Got another letter few weeks back.

And recently even got a phone call stating they are calling on behalf of insurance company XYZ and want to confirm if Sushirolls got their analysis sent recently in the mail...

Positively the Feds are looking to block the acquisition of Change Healthcare by UHC.
Soon, if UHC goes unchecked we will have a single payer health system in America - not government run - but UHC run.