Crack Insurance Codes Before They Crack You

Published September 15, 2016

Physicians who bill insurers or the federal government for their patients’ health care costs will become responsible this fall for incorporating almost 7,000 diagnostic code changes into their practice of medicine and keeping of electronic medical records (EMR).

Many doctors will avoid this burden by billing their patients directly and using EMR software designed with patient care as its primary goal, instead of compliance with federal requirements.

Starting in October, 5,739 new medical codes will become valid, 850 will be revised, and 323 will be deleted from ICD-10, the most recent version of the International Statistical Classification of Diseases and Related Health Problems, a list of diagnoses maintained by the World Health Organization (WHO), according to the reference website

The code changes will take effect exactly one year after the federal Centers for Medicare and Medicaid Services (CMS) transitioned from ICD-9 to ICD-10, prompting insurers and health care providers who bill third-party payers to do the same.

To help insurers determine whether to reimburse doctors for a procedure, insurers require physicians to indicate a patient’s ailment with an ICD code, in addition to a Current Procedural Terminology (CPT) code indicating the patient’s course of treatment.

Physicians typically use EMR software to help them bill insurers with ICD and CPT codes. The software also helps doctors comply with federal reporting requirements. The most compliant doctors are likelier to receive higher reimbursements for patient care from CMS. Doctors in the lowest percentile of compliance face financial penalties under the Medicare and Children’s Health Insurance Authorization Act (MACRA) and Merit-Based Incentive Program (MIPS).

Some doctors weary of the code culture of mainstream medical practice in the United States are gravitating to direct-pay models, such as cash and direct primary care practices. Direct-pay physicians avoid insurance code requirements by billing patients directly instead of through insurers or CMS.

Dr. Kathleen Brown converted her practice, Oregon Coast Dermatology, in Coos Bay, almost entirely to a cash practice in 2011. For the previous 16 years, she had billed patients primarily through third-party payers. When Brown “opted out,” as some call it, of billing Medicare and insurers, she posted her prices online for her patients to see.

“Since we do not accept insurance, we are able to be transparent about our pricing, and we charge exactly what we say we do,” Brown’s website states. “We are not a concierge practice and therefore do not charge an upfront fee to be a member of our practice.”

Patients settle up with Brown on their way out of her office after she has treated them. Her three-tiered price structure bills patients for every five minutes of care, starting at $38, $44, and $49, dependent on the skill level required. For each additional 5-minute block, Brown charges an additional $27, $33, or $38, also dependent on the level of treatment patients need.

If a patient desperately wishes to submit the cost of his or her visit to an insurer for reimbursement, Brown will accommodate the request – for a fee, she told me during an episode of the Health Care News Podcast that aired in August. Producing an ICD-10 or CPT code may not be patient care, but it’s good customer service when a patient asks. Fewer than one-third of her patients do.

Other doctors who have opted out of the third-party payer system, including code requirements, have flourished with the help of EMR software designed to serve direct-pay physicians and patients. Dropping CMS as a payer frees doctors to use EMR software custom-built to enhance patient care, not jury-rigged to harvest codes and other data.

Dr. Fatima Jaffrey opened Crescent Medical, her direct primary care (DPC) clinic in Oklahoma City, Oklahoma, in 2014. From day one, Jaffrey has used an EMR platform called to help her collect only as much information as she needs to provide superior patient care, as determined by Jaffrey and her patients, not federal EMR or coding requirements. was developed by DPC physician Josh Umbehr as his alternative to using nine incompatible EMR platforms for the first two years after he opened his clinic in Wichita, Kansas.

The catch:, while HIPAA-compliant, does not comply with federal reporting requirements under CMS’ “meaningful use” program (which, under MACRA, is being absorbed by MIPS).

This is because a chasm separates the EMR that physicians actually need to treat patients from the EMR the government demands most physicians use, as Jaffrey and Umbehr told Health Care News in September.

“The EMR most often used by those of us in DPC is a completely different EMR and is structured for DPC, strictly for the care of that patient specifically,” Jaffrey said. “We’re not paid by the code entered for the patient.”

“Codes aren’t health care,” Umbehr said. “They are industry bureaucracy. Surprisingly, we can care for patients without those codes and, in fact, have significantly more time to focus on the patient rather than on the paperwork.”

Physicians who are stuck in the code culture – unlike Brown, Jaffrey, and Umbehr – should not get too comfortable with ICD-10. WHO will release ICD-11 in 2018.

Doctors should think hard about cracking the codes before the codes crack them.

Michael Hamilton ([email protected]) is managing editor of Health Care News, author of the weekly Consumer Power Report, and host of The Heartland Institute’s Health Care News Podcast.



The Partnership to Fight Chronic Disease (PFCD) today released a first of its kind poll examining Americans’ concerns about their health care and coverage. The survey of more than 20,000 health care consumers, conducted by Morning Consult, underscores the importance of access to health care services in the fight against chronic disease. The survey takes a closer look at how consumers use the health care system, the barriers they face and the solutions they would like to see; the data is available at the state and Congressional district level.

“We hear a lot about the mechanics of our health care system, but not enough about how the system helps people or affects family finances,” said PFCD Chairman Ken Thorpe, Ph.D. “This survey shines a light on the challenges consumers face when it comes to using their health care coverage. Unfortunately, this survey finds patients are facing less coverage and higher costs than they expected, making access to care – especially for those with one or more chronic conditions – more difficult.” …

Among the survey’s key findings:

  • 7 in 10 consumers report that they or someone they know have had difficulty using their health insurance coverage in the past year;
  • Consumers’ top concern is premium costs and its impact on family budgets;
  • Consumers want a better understanding of their true out-of-pocket costs before receiving care.

“Now is the time to motivate change and innovation among our political leaders to improve access and quality in health care,” concluded Thorpe. …

SOURCE: Business Wire


Imagine getting the bill for an ordinary dinner and noticing, in tiny print, that the restaurant charged you $40 for coffee. Surely you’d be upset.

It turns out that hospitals inflate specific prices all the time in ways that aren’t transparent to the patient, according to a new study that appeared today (Sept. 7) in the journal Health Affairs.

Researchers at Johns Hopkins University in Baltimore found that many hospitals charged more than 20 times the cost of some services, particularly for certain services like CT scans and anesthesiology. The researchers said that the pattern of charging suggests that hospitals strategically look for surreptitious ways to boost revenue.

“Hospitals apparently mark up higher in the departments with more complex services, because it is more difficult for patients to compare prices in these departments,” Ge Bai, who led the study and is an assistant professor at the Johns Hopkins Carey Business School, said in a statement. …

The markups occurred in all types of hospitals, both private and nonprofit, the researchers said. Yet hospitals with the highest markups, on average, tended to be for-profit hospitals with strong power within their markets, because of either their system affiliations or their dominance of regional markets. In other words, those hospitals that can mark up prices, do mark up prices, according to the researchers.

The pricing can have serious consequences for the payer, the researchers said. For example, hospitals whose costs for a CT scan run at about $100 may charge a patient $2,850 for a CT scan, the study found. …

In 2013, the average hospital with more than 50 beds had an overall charge-to-cost ratio of 4.32 – that is, the hospital charged $4.32 for every $1 of its own costs. However, at most hospitals that they examined, the researchers found that the charge-to-cost ratio was far higher in departments that were technologically advanced. The highest was in the CT department, with an average ratio of 28.5. …

SOURCE: Christopher Wanjek, The Huffington Post


New data from the U.S. Census Bureau released Tuesday confirmed that only 9.1% of Americans went without health insurance in 2015, the lowest rate ever recorded and a figure that has been pinned to the Affordable Care Act’s coverage expansion.

Uninsured rates went down across nearly all races, age groups and income levels from 2014 to 2015, according to the Census Bureau’s 2015 report. Young, working-age adults and Hispanics continue to have the highest uninsured rates. Coverage rates also stayed stable or increased across employer health plans, Medicare and Medicaid.

The uninsured rate in 2014 was 10.4%, a sharp decline from 13.3% in 2013, the year before the ACA’s Medicaid expansion and marketplaces went live. …

However, separate census data showed that medical out-of-pocket expenses dragged 11.2 million people into poverty in 2015, a potential symptom of the shift of moving employees and individuals into health plans that have higher deductibles, copays and coinsurance rates.

“This (report) is really validating the point that the law is working to expand health insurance coverage,” said Erin Trish, a health policy professor at the University of Southern California. But, she said, “There’s definitely evidence suggesting people are still having a hard time making their payments for the premiums and out-of-pocket expenses.” …

SOURCE: Bob Herman, Modern Healthcare


Republicans are slamming the Affordable Care Act’s (ACA) lack of accountability in light of two new reports showing the health care law is vulnerable to fraud.

“This report unfortunately tells us more of what we already know – that the Obamacare federal exchanges have been riddled with problems since day one,” said House Ways and Means Committee Chairman Kevin Brady (R-TX) in a statement issued with several other GOP Committee Chairmen.

Brady and the other top GOP policymakers say they are concerned by the fact that undercover operations by the Government Accountability Office (GAO) in 2015 and 2016 got through the ACA’s fraud prevention measures. For its 2015 analysis, the federal investigative agency successfully used “fictitious applications for subsidized health plans” ten times, and was approved for Medicaid coverage in seven of eight other fake applications.

Four states were targeted for investigation – New Jersey, North Dakota, California and Kentucky.

The 2016 investigation found that in addition to approving eight fraudulent applications, four applications were approved despite lacking proof of eligibility from prior years’ investigations. The applications were submitted through federal exchanges in West Virginia and Virginia, and California’s state marketplace. …

The law has faced other criticisms of late, as insurers are pulling out of many states and a majority of state-run healthcare exchanges have collapsed.

SOURCE: Dustin Siggins, The Stream