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  coding strategy

The Patient Perspective

Careful explanation of services and costs can reduce confusion

JOHN RUMPAKIS, O.D., M.B.A.

You know, it’s funny. I spend most of my working moments devoted to keeping my colleagues safe and profitable by making sure that everyone is well aware of the rules, regulations, policies and laws surrounding the patient encounter. But, I haven’t focused too much on the other side of the transaction: coding from the consumer perspective.

Most patients really don’t understand their benefits, or are unable to make the distinction between managed vision care benefits and their medical coverage. And, despite the often heroic efforts of our staffs, they continue to misunderstand — or even worse, misinterpret — the walkout statements that we provide or the explanation of benefits (EOB) that they receive from the insurance carrier.

The consumer view of coding should be considered in our day-to-day activities, particularly because many audits are triggered by a patient complaint regarding a statement he or she received with charges that no one explained. Remember, we have a requirement to disclose all charges to our patients, particularly those they may have responsibility for. Here’s some additional food for thought.

Five characters

The only description of the services, procedures or products that we have painstakingly memorialized in our medical record is a five-character code that means absolutely nothing to our patients. Yet, this code is the only legal representation of what is contained in, and substantiated by, our medical record. So, if the code that appears on a patient’s walkout statement or EOB is associated with a fee that no one explained, it creates some suspicion in our patient’s mind that “my doctor is taking advantage of me” or “my doctor is ripping off the insurance carrier.” It doesn’t take a lot for the patient to call the office to find out what’s going on, and if he or she doesn’t get a satisfactory explanation, reporting the doctor to the carrier is often the next step. Now, this may or may not be a common occurrence in your practice (let’s hope not!), but one can easily see that this can create exposure for the practitioner.

Preventing exposure

Preventing or reducing exposure is simple: Communicate with your patients. Explain the codes and your fees. Discuss what the expected carrier coverage will be, what they should expect to pay, whether their current insurance requires a co-pay for their visit or whether the services provided apply to their deductible and they must pay in full.

Properly use an Advanced Beneficiary Notice when you have a specific reason to believe that the carrier may not provide coverage. Have patients choose the appropriate option and sign the form. This properly discloses to patients what is going to be done, and how much it may cost before the service is actually provided.

Careful communication

Coding is what we have to do to accurately represent what we did, but being sensitive to the consumer side of this situation is just as important for us to do well. Providing an accurate, easy-to-understand explanation about the services provided and the expected financial impact can make all the difference to a patient’s perception of what occurred during the encounter. OM

DR. RUMPAKIS IS FOUNDER, PRESIDENT AND CEO OF PRACTICE RESOURCE MANAGEMENT, INC., A CONSULTING, APPRAISAL AND MANAGEMENT FIRM FOR HEALTHCARE PROFESSIONALS. E-MAIL HIM AT JOHN@PRMI.COM, OR VISIT TINYURL.COM/OMCOMMENT TO COMMENT ON THIS ARTICLE.