Payments > Insurance Payments

Billing provisional and/or rule out diagnoses

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Sophrosyne:
I think I didn't explain myself very well. The doctor DID do an initial assessment and has documented a few provisional diagnoses for the patient. However, she intends to do some psychological testing as well to determine a final diagnosis. She was just wondering if we could file these visits as the patient is seen (certainly NOT before the services are provided!) with the provisional diagnosis. This diagnosis MAY change after she has completed the testing. What she is looking to avoid is waiting until all testing is done and some $2000+ dollars billed to file and see if the insurance is going to pay. She is concerned with 1. Sticking the patient with a huge bill that they weren't prepared for and 2. Not getting paid if the insurance doesn't cover for some reason. I wouldn't be surprised if that's just the risk she has to take, but she wanted me to look into this.
At this point I'm thinking that perhaps the thing to do is file with the provisional diagnosis as the patient is seen. And if/when the doctor finds a more fitting diagnosis during/after testing, use that diagnosis from that point forward. Does this seem appropriate? We certainly aren't trying to do anything illegal here!

PMRNC:
MUCH of what your asking really is clinical decision making which none of us are really qualified to do. For most part there are DOZENS of mental health diagnosis's that exist that CANNOT be established by way of psychological testing. Yes, the testing is expensive but from a clinical stand point only she is qualified to ascertain the condition that is suspect. I can't tell you that if she is doing a lot of testing that carriers won't flag it if she's doing a lot of it. Clinically she only should be making clinical decisions for testing based on suspect diagnosis, MUCH of the testing is not mean to rule out MOST diagnosis's in mental health.  Like you mentioned this is a cost of doing business and she has to make clinical decisions this is not really a "billing issue" because performing medical tests based on the patient's insurance is definitely a NO NO.  Carriers also usually require a separate authorization for testing and they have a means of establishing medical necessity for psych testing. For example Value options requires their own form to authorize testing, the authorization is then given for a certain amount of testing hours (8 for value options, for my plan example) 

With that in mind I would recommend looking into what the patient's carrier's requirements are, submit the clinical info they require and let the carrier authorize. If the carrier does not authorize the testing you still need to refer to the contract if one exists with the carrier to see if it's billable to the patient. Some plans won't let you, some will.

Merry:
I must add..please do not bill until you have a definite diagnosis. This information is frequently stored at a large clearinghouse, MIB in MA. An incorrect diagnosis can really hurt someone trying to get life insurance or disability insurance.
I had a derm who insisted on coding for a malignant lesion that he had removed before the path report came back. I caught the claim and held it. The lab report was benign but had this been reported initially in the days of pre-existing conditions and health insurance or even getting life or disability insurance, the patient would have been screwed.

Merry

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