December 21, 2009 by David Gillaspie
CODE CHECK FOR FUN AND SAVINGS
by David Gillaspie
A guest at DG’s B&B Christmas party came on crutches. Broken foot? Twisted ankle? Neither. He had a wire screwed into his broken toe. He expects a full recovery with no aftereffects. Then he read his medical bill, carefully.
“You open the billing envelope from your recent doctor visit and scan down to the amount owed. If it says zero, you put it down and open the next envelope. You know your insurance company pays the bill because you pay the insurance company.
That’s how it worked until I took a better look at my bill. CPT stands for Current Procedural Terminology. It is a registered trademark of the American Medical Association, so you know its heavy duty. If that’s not heavy enough, it’s on the AMA page for Coding Billing Insurance.
If a bill doesn’t look right, then I make it right. I did the research and made the calls, starting with enacted Oregon Senate Bill 355 from the 75th Oregon Legislative Assembly, 2009 Regular Session: “Relating to an electronic prescription monitoring program; appropriating money; limiting expenditures and declaring an emergency.”
Since it didn’t mention insurance fraud I looked at the dead House Bill 3092: “The following summary is not prepared by the sponsors of the measure and is not a part of the body thereof subject to consideration by the Legislative Assembly. It is an editor’s brief statement of the essential features of the measure as introduced.
Creates crime of insurance fraud. Punishes by maximum of 10 years’ imprisonment, $250,000 fine, or both.”
This sounded like it had the sort of teeth insurance fraud investigation needs. It would have made claims fraud a specific crime and granted immunity for reporting insurance fraud, but it died in the Oregon House.
Shouldn’t insurance fraud be a crime in Oregon? Or is it so minor that it’s not worth the trouble? The National Health Care Anti-fraud Association, the NHCAA, doesn’t think so.
The numbers are huge. From nhcaa.org:
“The United States spends more than $2 trillion on health care every year. Of that amount, NHCAA estimates conservatively that at least 3%–or more than $60 billion each year–is lost to fraud. This loss directly impacts patients, taxpayers and government through higher health care costs, insurance premiums and taxes. Additionally, health care fraud often hurts patients who may be subjected to unnecessary or unsafe procedures or who may be the victims of identity theft.”
Sixty billion dollars each year lost to fraud and Oregon is one of two states not included on the NHCAA’s list of state fraud bureaus with investigative and prosecutorial jurisdiction over fraud against private and/or public health insurance plans?’ Vermont is the other state missing from the list.
Oregon does have a Worker’s Compensation Division with a lead investigator who decides which resources and technical expertise to deliver, but what about non-Worker’s Comp problems? The Oregon Medical Board has a claim report for negligence and malpractice, but not health care fraud?
The FBI takes health care fraud seriously, and so do you, but how do you interpret medical billing codes? Start with the numbers. Here’s a sample from http://www.qualifiedsurgeons.org/ahp/cptcodes.pdf.”
CPT codes for the physical therapy/occupational therapy/speech-language pathology services in the 97000 series:
97001 Pt evaluation, 97002 Pt re-evaluation, 97003 Ot evaluation, 97004 Ot re-evaluation, 97010 Hot or cold packs therapy, 97012 Mechanical traction therapy, 97016 Vasopneumatic device therapy, 97018 Paraffin bath therapy, 97020 Microwave therapy, 97022 Whirlpool therapy, 97024 Diathermy treatment, 97026 Infrared therapy, 97028 Ultraviolet therapy, 97032 Electrical stimulation, 97033 Electric current therapy, 97034 Contrast bath therapy, 97035 Ultrasound therapy, 97036 Hydrotherapy, 97039 Physical therapy treatment, 97110 Therapeutic exercises, 97112 Neuromuscular reeducation, 97113 Aquatic therapy/exercises, 97116 Gait training therapy, 97124 Massage therapy, 97139 Physical medicine procedure, 97140 Manual therapy, 97150 Group therapeutic procedures, 97504 Orthotic training, 97520 Prosthetic training, 97530 Therapeutic activities, 97532 Cognitive skills development, 97533 Sensory integration, 97535 Self care mngment training, 97537 Community/work reintegration, 97542 Wheelchair mngment training, 97545 Work hardening, 97546 Work hardening add-on, 97601 Wound(s) care, selective, 97602 Wound(s) care, nonselective, 97703 Prosthetic checkout, 97750 Physical performance test, 97755 Assistive technology assess.
Now that you are warmed up to CPT, this ought to make sense: