September 20, 2021

Medicare billing

Margaret Turk


First of all I would like to thank the many people who contacted me to thank me for my letter regarding the clinic lab being moved to the hospital and the administration of the clinic by the hospital. There wasn’t a single, negative comment about my letter. Everyone, from former and current employees to patients, had a story to tell of their bad experiences either with administration or their inability to see their medical provider as they were at out-of-town clinics.

As you may know, I worked for many years at the Creston Medical Clinic until the physicians went to work for the hospital a little over 10 years ago. One of my most important responsibilities was to keep up to date on Medicare rules, regulations and fee schedules. At that time, physicians had to bill Medicare to strict coding guidelines. Without getting too technical, there are four levels office visits and each had increasingly higher requirement for the level of examination and the time spent with the patient and the documentation of the service. As we were reimbursed about half for Medicare and Medicaid patients what private insurance paid it was important that the coding was accurate.

I did internal audits of the medical providers and then reported to them if they were in compliance with Medicare. Most of the time, I found that the physicians were under coding, which means they did not code as high as they could for the documentation they dictated and the time spent with the patient.

The Creston Medical Clinic was one of that last independent medical clinics in the state. It bothered me that hospitals were so intent on buying up all the medical clinics. How could the hospital pay the physicians so much more? I believe there are several factors that created this scenario. Firstly, Greater Regional is designated a “critical access rural hospital.” Small rural hospitals with 25 beds or less were given this classification to insure their survival in the rural areas and was a good thing. These hospital are allowed to split the office visits into two parts each being paid twice what a private physician would be paid.

Then Medicare put in some requirements that everyone had to adopt electronic medical records to be paid in full. These systems are very expensive and smaller providers who cannot afford to install these systems are paid less. One could assume that Medicare thought they would be able to keep track of the billing and services needed for the elderly. Unfortunately, they also opened the door to fraudulent billing. All the medical provider has to do is click a button saying something was done and it is filled in electronically whether it was done or not. It also required the poor medical provider to sit at a computer typing in all this data rather than looking at the patient and actually examining them. I’ll bet there is not a single one of you who can say you are getting a better examination now than previously.

The final straw was when some bureaucrat convinced Medicare that if they did “wellness exams”, they could somehow transfer all us 80 year olds to 40 year olds. All this required was using a new code (G0439) that has a one-line description and performing what is basically a hundred questions about do you have a night light, or are you afraid of falling, etc.

My son got a letter about his upcoming Medicare wellness exam wanting us to fill out all this information prior to his visit and even told him that if he had another problem he needed to make another appointment. If you need prescriptions filled there will be another charge along with $244 Medicare will approve for the wellness exam. When you get your explanation of benefits from Medicare look to see what other code is added for just refilling your prescriptions. If it is a 99214 the physician spent an additional 40 minutes on your other problems. If it is a 99215 it means they spent another hour with you. I’ll bet there isn’t one of you who can say that happened either.

My last wellness exam, Medicare paid $534.67 to the hospital compared to the $100 my private physician would had gotten for the same services. I cannot understand why Medicare has not noticed that since these exams were initiated they are paying more than five times what they paid previously for the same patient.

I believe the private insurances have noticed however, as my supplemental insurance has doubled in the last couple of years. I for one am going to decline the “wellness” exam next time and ask for an office visit for a check-up and to get my medications refilled. That is the only way I will know that the level of service I get and the level charged to Medicare will be consistent and there will actually be time to visit with my physician.