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According to Acupuncture Today,
...as to whether you may bill an E/M on each visit, the answer is a simple and direct, no.
Short Answer
No. Billing an office visit on every DOS is a risky billing strategy. Over time, you increase the risk of audit, and put your future profits at risk.
Bill OV codes at least 30 days apart. It's not unreasonable to bill an OV code if a patient presents a new diagnosis, but carriers are becoming more strict over time.
Long Answer
It creates administrative work and messes up your cash flow
Ideally, an insurance claim is paid 1) correctly as originally submitted, and 2) without having to argue with the insurance company.
It doesn't always work out that way. When it doesn't, our FUP department can contact the insurance carrier to identify the issue and, when possible, convince the carrier to reprocess and pay the claim.
Acubiller collects data and metrics on the services we provide. Our data confirms that clients who bill OV codes on every visit are our biggest FUP requesters.
In order to get paid, these clients require intensive administrative work on hundreds or thousands of insurance claims per year. The more claims they file, the more FUP they require.
This is not an indictment of insurance carriers. It indicates a clinic's administrative inefficiency due to inappropriate billing practices.
The way to address this inefficiency is to bill conservatively. Shoot for 4 units max per DOS, and bill OV codes infrequently.
It indicates fraud, waste, or abuse
Insurance carriers are obligated to protect the funds they manage against fraud, waste, and abuse. Humana provides straightforward definitions for these terms:
Fraud is generally defined as knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any healthcare benefit program or to obtain (by means of false or fraudulent pretenses, representations or promises) any of the money or property owned by, or under the custody or control of, any healthcare benefit program. (18 U.S.C. § 1347)
Waste is overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the healthcare system, including the Medicare and Medicaid programs. It is not generally considered to be caused by criminally negligent actions, but by the misuse of resources.
Abuse is payment for items or services when there is no legal entitlement to that payment and the individual or entity has not knowingly and/or intentionally misrepresented facts to obtain payment.
Examples of abuse include:
- Charging in excess for services or supplies
- Providing medically unnecessary services
- Billing for items or services that should not be paid for under the plan
Examples of fraud include:
- Billing for services that were never rendered
- Billing for services at a higher rate than is actually justified
- Deliberately misrepresenting services, resulting in unnecessary costs to the Health Plan, resulting in improper payments to providers or over-payments
Waste is a little harder to describe, but Providence describes it as follows:
Waste is health care spending that can be eliminated without reducing the quality of care, such as overuse (prescribing too many antibiotics), underuse and ineffective use of treatments or medications. It is also the inefficiency in redundant testing, delays in treatment and making processes unnecessarily complex.
Some eval is implicit in acupuncture, so it's inappropriate to bill an OV every time
"It is, in fact, compulsory to perform an examination of your patient in order to determine their condition, determine that acupuncture is an appropriate mode of care, and determine a subsequent acupuncture treatment protocol. In fact, I would assume that it would be considered unprofessional conduct to not do an examination prior to the initiation of care. The key factor on the billing is to demonstrate the E&M as a separately reimbursable service by appending the code with modifier -25." ~from Acupuncture Today
If I'm not supposed to bill an OV every time, why has the carrier paid it for years?
That's a good question, and we don't know.
Our best guess is that this is a widespread issue, insurance claim processing is largely automated, and carriers have struggled to address the issue effectively.
What we do know is that insurance carriers can audit you and demand repayment; and they've been cracking down on the overuse of E/M codes in recent years. Some of our highest-volume clients have seen negative cash flow as a result.
A clinic might see this as a "drop in payout", but it's more like a cessation of overpayment. Adjusting to a cessation of overpayment tends to be financially difficult for clinics.
A conservative billing strategy avoids all of these problems. If you're looking for guidance, check out our FAQ article How should I bill?
