Question & Answer
A member needs advice on how to handle billing after hours calls.
Q: Dear Dr. Jorgensen, I am wondering what if anything can be done to bill for after hours calls. As you know, most insurance companies require 24-hour coverage but do not reimburse for this service. My only guess to bill for this service is 99050-99054. Please comment on the billing of after hour calls.
A: As you have noted, payors require 24/7 coverage and often times will not credential a provider unless or until they can provide such access. In the American healthcare system it has become the norm. However, there are means by which to be paid for such time. I will try to outline them below.
Telephone calls are by far the most time consuming after hours issue with which on-call providers must deal. To date many providers felt this was our duty to our patients, an ethical imperative, thus they chose not to pay. Not so in an increasing number of health plans.
A National Public Radio piece a few months ago well detailed the rise of electronic medical advice. Unlike prior years, there is now a copay and an insurance payment attached for some plans. Codes 99371-99373 (RVU’s are 0.390, .97, 1.93, respectively) are being used for telephone calls and even e-mail, in some settings, are being reimbursed.
For years it has astounded me that I freely (literally) give telephone advice at night or on the weekends, but am not only not paid for it, but am fully liable in the event of an adverse outcome from my wee hour cerebral offerings. Fear not, we can now (and like many matters it is payor dependent) charge for telephone calls and get paid. Most payors are not freely advertising this, but it is worth a phone call to provider relations to see if your payor mix will reimburse for it.
Remember, if you charge for it, you have to bill everyone, even your cash patients—lest you be perceived as being discriminatory! Not all payors will pay for it,
but you should submit the claim anyway to be consistent.
Documentation
One last note is the imperative of a medical record documenting the phone conversation took place or
making certain the e-mail is in the patient record. Medicolegally any advice should be documented, but in this sense it also serves as proof that you gave telephone
or e-mail advice for which you want reimbursement. Some payors have begun charging copays to beneficiaries for e-mail or telephone calls. The insurer saves money on the visit, the patient doesn’t have to
wait to be squeezed in or added on and the provider
can answer calls between patients, at night at home or early in the morning.
This creates a cost effective and potentially more convenient alternative to a face-to-face encounter. However, many patients are objecting because of years
of conditioning that telephone call advice was free. This will likely take some time to be fettered out, but with growing electronic communication electronic accessibility
to real time health information will likely become more ubiquitous.
Privacy
One last item on this matter regards privacy. In terms of web-based communications, I would check with your local healthcare attorney regarding HIPAA Title II issues on privacy and e-mail. Firewalls exist, but some are better than others. We must protect ourselves and our patients from public purview of assumedly private interactions.
More regular payment (Medicare and Medicaid excluded) can be found billing codes for after hours (99050), Sunday/holidays (99054) or for seeing patients between 2200-0800 (99052). Some payors will not pay
for these or may deny payment initially. However, many will ultimately pay.
One pediatric practice in Connecticut received an additional $30,000 in income for the Sunday/Holiday codes. Any of these codes can be used for rounding, admits, consults, office visits, etc. in addition to the
E&M codes (99212-22215, 99241-99245, 99251-99255, 99221-99223, 99231-99233, 99261-99263, etc.) or any procedures that might be done. Naysayers often don’t bother billing these, but unless you do you won’t find
out who pays and who does not. Again, you must be consistent and bill everyone even though you know
some will not pay.
Resubmit, Resubmit, Resubmit
Do not be afraid to resubmit for in some situations I have had organizations freely admit to denying payment initially hoping many will not resubmit. A national medical management study in the late 1990’s found about 50 percent of offices do not resubmit claims if denied. This makes good business sense for the insurers as they get to keep over half the money for these services and if they deny it two more times the keep nearly 90 percent
of the money for those claims.
If you did the work and want to receive payment do resubmit and follow up with notes and/or a telephone
call if necessary. Persistence pays off and a system to do resubmissions should exist for in some instances you have to resubmit multiple times before payment is received.
Is it fair? No, but hopefully the class action suits against all the major payors will stop much of this bullying.
If in the middle of the night your office provided services on an emergent basis—and hopefully if your doctor got out of bed in the middle of the night it was
an emergency and not just for a birth control refill.
You can charge the appropriate E&M code and/or a procedure, if performed and documented, in addition
to a 99058.
Some payors have attempted to ward off payment by saying ‘you didn’t submit an urgent or emergent ICD code.’ No such beast exists, but you can document that it was emergent or urgent. In my office if we see someone emergently, my staff starts the history (we have electronic records and they do most of the history before I get in the room) with ‘Patient here on an emergent basis.’ I would advise having similar language in your provider’s notes as using this code can often prompt a record request to
verify emergent or urgent care.