The Health Care Codes Monopoly
Many people have no idea that there is a health care codes monopoly,
even know what it means. It’s time we did.
Billing Codes
The billing system of American health care is based on a complex
coding system called Current Procedural Terminology (CPT)
codes). Established in 1966 by the American Medical Association
(AMA), the codes garner the AMA hefty annual licensing fees. Each
time a CPT code is used, the AMA gets paid.
There has never been a law against including codes to cover
all health care practitioners, but the AMA has developed very few
codes for non-medical practitioners. This keeps other practitioners
from becoming equal business partners in the world of
insurance reimbursement for services rendered.
CPT codes are designed to document what a medical doctor
does for a patient. Think of a department or grocery store where
every item has a bar code, and if it doesn’t, the item can’t be sold
without a clerk running back to the aisle to find the price. Swiping
a bar code across the cashier’s scanner not only calculates the
price but also automates inventory control and financial management.
It’s the same for health care: without a code there is no
way to calculate appropriate payment and no itemization of what
has transpired. It’s that simple.
The current coding systems cover only a fraction of what
is happening in health care—coded interventions are the only
transactions that are tracked, marketed, and reimbursed. This is
why so little is known about what transpires in the marketplace
with regard to health care practitioners who are paid cash.
Without codes for all types of health care practitioners we can’t
document the effectiveness of their care or the potential money
that is saved by including them in insurance reimbursement.
It’s a lose-lose situation. Patients lose, practitioners lose, and
the nation keeps losing millions of dollars paid out to ineffective
and costly drug-based medicine. For example, health care trends
are tracked by data obtained from insurance companies. Since
insurance companies can’t measure data they don’t have, they
have no way of knowing, for example, that patients who see midwives
have a much lower rate of cesarean section (about 10–15
percent) compared to patients who are delivered by obstetricians
with over twice the rate of about 30 percent.
Lack of relevant data is also why we can only depend on small
samples and surveys to tell us what forms of natural healing arts
people are using because we have no other way of gathering
the data.
It’s Getting Worse, Not Better
There used to be state codes (HCPCSIII) that individual states created
to meet their needs. The state codes were abolished in 2003,
costing many states’ Medicaid programs millions of dollars.
Square Pegs in Round Holes
Being required to fit everything a practitioner does into an
allopathic/medical code leads to a high degree of inexactness.
Because CPT codes include very few non-medical modalities,
many doctors must limit their practice to allopathic medicine so
they can get paid by insurance. This, in turn, limits the type of
care available to the public. Practitioners who use non-allopathic
modalities have to fit their care into a CPT code—square pegs
into round holes. For example, all states allow nurse practitioners
to bill directly for their care, but they lack appropriate codes.
So, while insurance companies may direct them to bill using CPT
codes, the American Nurses Association has determined that
CPT codes do not describe or document that the care is from a
nurse. The new ABC codes solve this problem for all practitioners
by giving each practitioner their own set of codes.
State of Exclusion
Due to discrepancies in state “scope of practice laws,” insurance
companies don’t know the scope of practice for each type of practitioner
in each state, and because of potential legal liabilities, they
just don’t pay for these services. To be fair, they don’t want to pay
a claim illegally, but it suits them just as well to not pay—it saves
them the hassle of processing claims without codes.
Color-shaded Areas Indicate a Portion of the Gaps
in National HIPAA Code Sets Addressed by ABC Codes
The graph shows practitioners left out
by the medical monopoly in coding.
ABC Codes
Knowing the limitations of the CPT codes, a unique company called
ABC Coding Solutions developed “ABC Codes” that describe services,
remedies, and equipment items used by all health care practitioners,
not just medical doctors. And, they include codes for most aspects
of alternative medicine as well, including homeopathic remedies.
Ms. Giannini, the CEO of ABC Coding Solutions, knew the health
care system was unhealthy, but it wasn’t until she experienced a
chronic illness that she became a victim of it herself. She struggled
with her illness for two years, going to medical doctors who billed her
insurance company a total of $15,000—all legally coded and absolutely
ineffective. After none of the medical treatments worked, it only
took a few visits with a doctor who provided care that was not in the
CPT codes, and $500 in out of pocket expenses, to get her well.
Ms. Giannini found it incredible that an insurance company
would gladly pay $15,000 for treatments that didn’t work but refuse
to pay $500 for treatments that did. The doctor who helped her get
well is one of millions of practitioners forced to operate outside
the “system,” one that also forces millions of patients like Ms.
Giannini outside as well.
Playing Monopoly
In 1993, the federal government told the AMA to create codes for
non-MDs, but they haven’t complied. It’s like asking Ford to create
service and supply codes for Chrysler! Nobody is going to willingly
stop something that works in their favor. Nurses have tried for
decades to get nursing codes by participating on a coding panel
with the AMA, without much luck. And, as of 2006, out of over
8,000 CPT codes for medical care, there are only four CPT codes for
chiropractors and acupuncturists, and massage therapists have
just one code.
Cut the Bureaucracy
ABC Coding Solutions keeps current on the legal scope of practice
of all practitioners in all 50 states, and ABC codes legally reflect
the practices of more than 3 million underserved health care
practitioners. But they are not meant to supersede the current
codes. When used together with CPT and government codes, ABC
codes support a complete, accurate, and precise documentation
of patient encounters and a common language for comparing
the economic and health outcomes of competing approaches
to care. The fact that ABC Coding Solutions can determine if a
code is legal or not saves billions in administrative costs and
wasted haggling over inappropriate codes.
ABC Coding Solutions estimates that using ABC codes will
save more than $51 billion per year in u.S. health care costs
when implemented across the health care industry.
For example, by using ABC codes in place of state codes that
were retired in 2003, the Medicaid Behavioral Health Department
in Alaska saved $2 million in one year. This department has
thus far used ABC codes to process more than 500,000 health
claim and payment transactions. And a Medicare Advantage
plan in New Mexico has paid claims on ABC codes for over five
years with similar outstanding results.
Having ABC codes will not change health care overnight—but
ABC codes are a big step in the right direction. unlike technologies
that cost millions and take years to return a profit, ABC
codes are a turn-key operation and begin saving everyone money
immediately.
With ABC codes, insurance companies, the government and
the public will have information to make informed decisions on
health care spending and reimbursement.
Consumer Directed Health Care (CDHC)
CDHC and Health Savings Accounts (hsas) are an attempt
to “solve” the problem of rising health care costs. They
raise consumer awareness about the real costs of health
care and help people make better decisions
about how to spend their health care dollars.
However, they are currently set up to use
only the medical model of care and AMA CPT
codes. They do not currently address the
demands of millions of people who want
alternate options to prescription drugs
and surgery.
ABC codes, however, allow all practitioners to effectively document their care and thereby potentially participate in insurance reimbursement and HSAs. Thus, ABC codes will help maximize the benefits of HSAs by providing consumer access to a wider variety of caregivers.
What You Can Do
ABC codes have been in use since 2003. However, ABC codes
need to leap over one more hurdle. They need to be named
a permanent government standard so that insurance reimburse
ment will be also become standard for all types of
health care.
ABC codes are authorized for use through October 2006. We
have until then to lobby our elected officials to have ABC codes
made a government standard. Please visit www.ABCcodes.com
for information on how you can urge your elected officials to
break the health care codes monopoly. From there you can send
your elected officials an email urging them to support naming
ABC codes a permanent government code-set. you may also
contact ABC Coding Solutions at 1-877-621-5465.
We don’t need more caregivers in America; instead, we need
to rethink coding. Coding is creating an artificial bottleneck for
direct consumer access to quality health care. Consumers are
demanding choice in health care. you can help create choice by
demanding that ABC codes are available to document the care
that consumers are already using.
Carolyn Dean, M.D., N.D., is a medical doctor,
naturopathic physician, researcher, educator, and wellness
consultant. She has written ten highly-acclaimed books,
including the widely read The Miracle of Magnesium, her
most recent, The Yeast Connection and Women’s Health, as
well as IBS for DUMMIES and Hormone Balance. Dr. Dean
disseminates the message of health and self-responsibility
in both private wellness telephone consultations
and at public seminars. See her Web site at www.carolyndean.com.
|
