Reimbursement rates for medical services have been steadily declining for years, with insurance companies becoming increasingly stringent in terms of what qualifies for payment for any given diagnosis or procedure performed. 

The medical insurance reimbursement strategy seems based upon a business model focused on doing the least, but getting the most. This is an understandable and even acceptable doctrine for businesses to follow in order to flourish, but unfortunately the strategy has trickled down from the overall insurance industry into medical office practices. 

In recent years, productivity-based compensation – an incentive based, commission-like type of salary for medical providers – has become more of a normal practice than an outlier. Relative Value Units, or RVUs, is one of the new methods used to determine compensation and salary configuration. 

One of the worries with productivity-based compensation is that it may encourage some providers to perform or bill for more services than they might otherwise do, based on the profit it may yield them. 

Currently, organizations such as the CDC, the United States Preventive Services Task Force (USPSTF) and the National Institute Health (NIH) issue standards and guidance for providing evidence-based medical care. Most providers follow these guidelines in order to promote best outcomes for their patients. However, these published practice standards do not always reflect the current remuneration practices of insurance companies.

Current Procedural Terminology (CPT) codes are typically reimbursed if the service is included in evidence-based guidelines and is usually disallowed if absent. However, there are loopholes for some CPTs that are reimbursable, even if they are not included in evidence-based guidelines. In practice, medical practitioners usually adhere to the concept of “reimburse it and it will be done.” 

Many practice managers and billing offices know the list of reimbursable CPTs intimately. Their job is to find better ways to get compensated for services rendered. Medical offices follow the letter of the law explicitly and often walk a fine line to maximize profits for the practice and insurance companies, while assuring that they are obeying legal statutes.

Let me list a few examples of unnecessary tests and procedures that I have seen performed in commissioned-based business model medical clinics, simply because the service is reimbursable:

  • Regularly performing chest X-rays on normal healthy 20-year-old patients who come in for a complete physical exam, despite the practice being recommended against by the USPSTF and other organizations
  • Ordering throat cultures with sensitivities to be sent out to a reference lab after a positive in-house strep test has been documented and antibiotic therapy initiated as part of the planned intervention
  • Requesting a urine culture after a urinalysis shows WBCs and nitrites on an otherwise healthy adult young female with a first time complaint of UTI symptoms, or ordering a urinalysis and a culture on every patient with a urinary complaint, despite the questionable clinical relevance of the results.
  • Promoting the practice of ordering an electrocardiogram on every patient with a cardiac related illness in a family practice, regardless of whether the patient recently underwent the procedure in a specialist’s office.

Although these practices are legal, they not necessarily ethically or morally right, and many go against treatment and screening guidelines.

Another problematic area is called-up billing – the practice of charging at a higher acuity rating then the actual procedure or the level that was done. In medical billing, the depth of the visit for each patient is determined by multiple factors, but should be reproducible by examining the medical record. It is not a subjective assessment. Coding a 99214 for a routine office visit, when it should be a 99213 is so commonplace, it has become the standard of practice in most offices.

How much do you have to have documented in the history of present illness? How many systems do you have to have checked off in the review of systems? How many systems do you have to have observed and documented in the physical exam? How much do you have to write in the plan?

Focusing on the bottom line financially has infiltrated practice management in medical offices. Many practices carefully measure these factors, and some actually teach providers techniques to maximize billing during in-services. It is important to remember that although checking the appropriate boxes will garner more reimbursement, it does not necessarily translate into a more in-depth experience for the patient.

The advent of electronic health records (EHRs) and templates has also enable document completion with minimal writing. Using an EHR a provider can easily click a template that has built-in minimums for upcoding. Such practices are even noted as mandatory items in some systems, as steps that need to be completed before a provider can click to move on. This questionable practice is leading to a whole different problem with documentation fraud.

I always hold fast to the mantras “if it wasn’t done, don’t document it” and ” if it wasn’t documented, it wasn’t done.”  So many times upon reviewing a chart, I notice a review of systems symptoms reported (either negatively or positively) that later the patient states the provider had never asked them.

I’ve found the same on physical examinations. I once had a patient who said he had an earache, yet was seen the week before for a complete physical exam. Looking into his ear, I found it was completely impacted with cerumen. The chart from the previous week stated, “clear to TM bilaterally.”  It is questionable as to whether wax can build up that fast, but it certainly leaves room for doubt in the accuracy of that documentation.

The practice of medicine in modern times leaves all healthcare providers crunched for time, and we are all striving to get the patient the best care in the shortest amount of time. But are medical practices today becoming comparable to commission sales jobs?

These types of jobs, which entail a low base salary combined with a  percentage of what one sells, can be quite lucrative for those go-getters. But for providers who want to follow the treatment and screening guidelines and practice evidence-based medicine, this financial structure actually penalizes ethical conduct

As a result, healthcare providers who follow best practices often are slighted raises, bonuses and extra income, even though they are practicing good, quality medicine and only providing services the patient needs. 

During my formative years in medical training, I learned billing practices from a community health center, where our focus was not on a traditional business model. I did the absolute most for my patients for the least amount, because our patient population had no insurance and no money. I do the best I can to follow the principles of medicine I was taught. I treat my patients following evidence-based guidelines, without padding my charts and without ordering unnecessary tests.

So many healthcare providers are trained in the industry standard, and to them the business model is completely normal. Working at a community health center I did not get paid as well, but I certainly slept better at night. Instead of seeing patient’s as dollar signs, focus on the core ideals of practicing medicine to do the most good for the most people, and you, too, will be able to share in those restful nights of sleep.

Gerald Erickson, MMSc, PA-C, works in family practice, and is a clinical assistant professor and associate clinical coordinator in the department of physician assistant studies at Mercer University in Atlanta.