Specialists like Houston otolaryngologist Ronda Alexander, MD, rely heavily on consultations. But now that one major commercial payer will no longer be paying for them, she’s says it’s going to make it more difficult for many specialists to get compensated for the extra time and work those services require.
United Healthcare is eliminating payment for consults in two phases – one that took effect June 1 for certain services, and their complete elimination starting in October.
United says the change is an effort to align with the Centers for Medicare & Medicaid Services’ (CMS’) policy that eliminated payment for most consults in 2010. United originally planned to implement the policy in 2017, but the Texas Medical Association and more than 35 other medical and specialty societies persuaded the insurer to delay it.
Physicians used to billing for those services should take note of United’s new policy, which Dr. Alexander says could create an access-to-care problem.
“By taking this away, while they say they’re trying to align with the CMS payment structure, they may in fact be limiting access for their members to advanced services and specialty care. Some physicians may simply not take United Healthcare anymore,” particularly those rural and underserved area physicians who are operating on thin margins to begin with, said Dr. Alexander, who practices at UTHealth in Houston.
More work, less pay
Consults, Dr. Alexander explains, garner more payment than standard evaluation and management (E&M) services to account for several extra requirements.
“We have to document that there has been a request for the patient to come see us. We have to document our opinion of the patient’s recommended care. And then we must communicate our opinion to the physician who sent the patient to us,” she said. “All of that is above and beyond the actual taking care of the patient. That additional payment really helps us cover the cost for us and our staff of communicating with the other physician and making sure that we have the consultation request documented.”
The affected CPT consult codes include 99241-99245, which cover office and other outpatient consultation services, and codes 99251-99255, which cover initial inpatient consults. Effective June 1, United eliminated coverage for those codes for any physician or practice whose contracts are based on a CMS fee schedule for 2010 or later. On Oct. 1, United will eliminate those codes for everyone. Practices will have to analyze their fee schedules to see whether they can bill for consult codes through October.
In pushing for a delay, medicine wrote to United in 2017 stressing the importance of educating physicians on proper coding if such a change went into effect. The letter also emphasized the impact on payments.
“If UHC does not pay for E&M codes at an amount comparable to consultation codes, it will result in a financial burden to practices that provide consultations,” medicine wrote. “Our hope is that UHC will continue to pay these practices for consultations at the level they are accustomed, so that their practices and ultimately patient care does not suffer.”
United didn’t comment for this story, other than telling Texas Medicine that it’s eliminating payments for consults to align with CMS. The insurer has not announced any plans to adjust its E&M codes in response to TMA’s request.
In a March 2019 network bulletin in which United announced the new policy, the insurer directed medical practices to “bill consultation services in accordance with current evaluation and management guidelines published by CMS.” United recommended that physicians bring their fee schedules up to date to align with CMS’ current reimbursement structure. To read United’s network bulletin, visit tma.tips/unitedbulletin.
Specialists may try to compensate for United’s new policy by providing more complex care and thus submitting higher-paying codes as part of their billing. But if you do that, you’d be better make sure you have the documentation to support it, says Genevieve Davis, TMA’s associate vice president of payment advocacy. Otherwise, a billing audit may turn out badly.
The fact that CMS is often a trendsetter for commercial plans raises the apprehension of other private payers following United’s lead. Dr. Alexander says health plans “tend to go like dominoes” when their competition introduces policies they find sustainable.
Not paying for consults, she adds, could create two categories of physicians, both with potentially negative impacts for patient care.
“There are going to be some doctors who are going to not do consultations in this way and are just going to take care of the patient and give the patient the information and tell them to relay the information to their primary care doctor,” she said. “Then there are going to be others who are going to absorb the cost of still doing it. That has ramifications down the line.
“Those who absorb it, they’re going to be a little less fiscally solvent. And those who don’t, it puts them at risk of not communicating effectively with the physicians they’re partnering with in primary care.”
Tex Med. 2019;115(7):36-37
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