[Ohioaap-practicemanagers] Reimbursement for simultaneous "well visits + acute" clinic visits

[Michele Dritz]

I have been told by United Healthcare Medicaid administrators that they
fully reimbursement for those visits — and that they’d like to know if that
is NOT what is actually happening — but my practice does not have UHC
Medicaid patients to know if that is true.  However, across the board, both
our private & public insurers seem to be doing this practice of ~50%
reimbursement.  What are other people’s experiences with various insurers,
including UHC?

This question is particularly timely since the Ohio AAP is scheduled to
host a Roundtable event with providers, insurers & others interested in
adolescent health next week.  The focus will be on policy strategies to
help improve adolescent well visit rates in the state, so the more
experiences the Ohio AAP can offer to insurance administrators at the event
from practicing providers about this reimbursement discrepancy, the
stronger our message can be about needed changes in Ohio.

Thanks for sharing your experiences!

Michele

-- 
Michele Dritz


On April 20, 2017 at 9:58:44 AM, Price, Jonathan (
jonathan.price at nationwidechildrens.org) wrote:

​Excellent question. I've experienced that 50% mark-down and would like to
hear about insurers who instead recognize the full value of
several services provided on the same day. They would be good examples we
could cite to the people who reduce the 'sick' part of the service.

   Jon
------------------------------
*From:* Ohioaap-practicemanagers <
ohioaap-practicemanagers-bounces at lists.deltaforce.net> on behalf of Michele
Dritz via Ohioaap-practicemanagers <
ohioaap-practicemanagers at lists.deltaforce.net>
*Sent:* Thursday, April 20, 2017 8:57 AM
*To:* ohioaap-practicemanagers at lists.deltaforce.net
*Subject:* [Ohioaap-practicemanagers] Reimbursement for simultaneous "well
visits + acute" clinic visits

I recently found out from our billing department that whenever we have a
patient encounter that we’ve billed as both a “well visit + an acute (or
follow-up) visit” using a modifier 25 (assuming it meets the criteria of
both), that the reimbursement ends up amounting to approximately:
the entire “well visit” reimbursement + ~50% of what would have been the
“acute or follow-up“ visit (regardless of level coded)

That is in contrast to receiving the full reimbursement if we have the
patient/family come back for a separate visit to take care of either
component of the care (the well visit or the acute issue), rather than
taking care of all of the things the day they are in clinic.  This is
particularly challenging as we attempt to better address the needs of our
adolescent population who we already know aren’t coming to clinic very
often, so we are often trying to address multiple things simultaneously to
make the most of every encounter.

I would be interested in hearing if others have OR have not found this same
issue.  Do you see a difference in practice between your Medicaid versus
Private insurers? Is there any other pattern you have noticed when you give
this type of care & bill appropriately?

Thank you ahead of time for your input & time!

Michele Dritz, MD
Dayton, OH

-- 
Michele Dritz
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