Ophthalmologists must dedicate more time to understanding approved practice and billing patterns

Issue: July 25, 2010

ByRichard L. Lindstrom, MD

Richard L. Lindstrom

Federal or state government now pays for the majority of health care in America, and we all must appreciate that the costs are staggering, approximately $2.2 trillion per year. The No. 1 cost is hospital care, which accounts for about one-third of the dollars expended. In second place are physicians and surgeons, at about one-sixth of the total cost. So, hospital and physician payments comprise about 50% of the total dollars spent. The next largest category is drugs and devices. Then comes nursing homes, long-term transitional care and hospice care. After that, the amount spent in any remaining single category becomes insignificant in the big picture.

If you were responsible for managing the cost of health care in America, you would have to focus on the cost of hospital care, physician services, drugs, devices and long-term care, representing more than 70% of the total cost. What kind of numbers are we talking about? In 2010, caregivers in these categories will receive $1.5 trillion or so in revenues.

Clearly it is appropriate and commendable that our government properly oversees the expenditure of such large amounts of taxpayer money. No one condones fraud and abuse, whether it be in health care or military procurement. Thus, we must all be prepared for ever-increasing scrutiny of our practice care and billing patterns.

Every ophthalmologist should anticipate some form of audit within the next 12 months, as the number of agencies charged with ferreting out even seemingly inconsequential errors in coding and billing is growing exponentially. These audits, much like an IRS audit of our tax returns, for most of us are at a minimum annoying, expensive and time-consuming; at their most extreme, they are downright frightening, and in the worst case, life-changing for us and our families.

We are all aware of colleagues whose marriages have failed under the pressure of a government audit, and with the current possibility of criminal charges on top of the monetary penalties associated with civil law, a physician can find his or her practice destroyed and family in ruin over inadequate chart documentation that does not support his/her billing for medical services. In a small number of cases, the extraordinary stress associated with such an experience has even led to suicide.

I wish I could suggest an easy answer. The unprecedented pressure on each of us to document and bill perfectly or face egregious penalties seems out of balance for a senior physician like me, who has dedicated a lifetime to always putting patients first, whether compensated for it or not. Being a dedicated, caring physician and skilled surgeon in today’s environment is not enough. It is imperative that we all take heed of the fact that our every activity is the target of continually increasing evaluation by individuals who have no way of knowing whether we are a caring physician making an honest mistake or a greedy charlatan trying to defraud a patient and the third party helping pay for their care.

In such an environment, each of us must dedicate more time to understanding and complying with approved practice and billing patterns. Our practice has a formal compliance officer, and we have an independent reimbursement expert randomly audit a series of charts from each of our physicians frequently. The auditors then provide in-depth feedback to the physician and their care extenders as to their findings. We have done this for years, always striving to improve, but the challenge to practice caring, compassionate and cost-effective medicine while providing perfect documentation and error-free billing is a formidable task.

Unfortunately, formidable or not, this is the environment in which we currently practice, and it behooves us all to know that every aspect of our professional life is under increasing scrutiny.