Pediatric Coding Alert

Pediatricians tend to be a soft-hearted group -- after all, they have chosen to spend their entire working lives almost exclusively with children. And they also see a lot of young, growing families, many of whom are struggling to make ends meet. So its understandable if they want to try to make things easier for these parents. However, giving discounts can upset their fee schedule.

Andrew Sinder, MD, a pediatrician with Mandarin Internal Medicine and Pediatrics of Jacksonville, FL, is worried about this. I have a dilemma on my medical billing , he writes. When parents are paying out of pocket because they are self-pay, or they have not met their deductible, I find myself downcoding. With managed care, I bill it as accurately as possible. Although this may seem unethical, it is difficult for me to resolve this problem. What do you suggest?

First of all, stop downcoding. Secondly, stop feeling guilty -- your heart is in the right place.
Here are some points to keep in mind when struggling with this dilemma.

1. The fairness trap. Dont confuse what you view as fair or not fair with your emotions. We do feel sorry for them, says Melanie Hartley, office manager for Batesburg-Leesville Pediatrics of Batesburg, SC. But we dont downcode, she contends. Its not fair. Not fair to whom? Not to anybody -- the practice, the insurance companies or the other patients who are actually paying.

2. Offer a hardship fee reduction instead. Parents who really dont have the money can be offered a reduced fee if they can provide evidence of hardship. Even HCFA allows this, says Peg Stevenson, CPC, coder for Providence St. Peters Family Practice in Olympia, WA, a residency program with two pediatricians on staff. Unfortunately, this means asking the parents to bring in a pay stub, if they are employed, she adds.

3. Just because a patient is self-pay doesnt mean the money isnt there. If a pediatrician just has a gut feeling a parent cant afford the visit, the pediatrician should step back and ask why he or she feels that way, says Stevenson. Many people who have insurance are actually paying more in monthly premiums than the parent who doesnt have insurance and who brings in a child for a well visit once a year and an occasional illness, she notes. Maybe the fact that theyre self-pay means they dont mind paying medical bills, she relates.

4. Connect with a public health program. Stevenson believes that if a parent is paying out of pocket, its because they dont mind paying. If they do mind -- or simply can't pay -- the pediatrician should help them connect with a public health program that will serve their needs. In most states there are tons of programs available, she says. Help get your patients parents into a situation where they can afford their medical bills.

5. Problems tracking productivity. A pediatrician who downcodes could be seriously damaging productivity tracking, Stevenson notes. The doctor is spending a certain amount of time doing much more work than his codes would indicate. If there is a high percentage of self-pay patients in the practice, and that pediatrician downcodes them all, the productivity levels will be way off, she says. This doesnt make that pediatrician look very good to the group. What he or she is doing is resulting in a loss of revenue for the practice.

6. Contracted payor problems. Theoretically, the real reason why it is a bad practice to downcode is that the insurance companies you contract with, if they get wise to this tendency, will demand that they get similar economic benefits from your largesse. Practically, Stevenson isnt sure that a payor could find out that it is happening. They would have to audit charts that arent their own, she says. The only way they could find out is to get their hands on your chart notes, to compare against the codes. And Stevenson says she doesnt think this is a hot issue among insurance companies right now. The person youre hurting the most when you downcode is yourself and your practice.

7. Rebate for same-day pays. What about giving patients who pay you the same day a discount? This would be an incentive based on your improved cash flow and elimination of billing expenses. You would give, say, a $10 discount for self-pay patients who pay you immediately. This way you are coding accurately, and you are not disturbing your fee schedule.