Osteopaths and insurance companies are duking it out over billing codes, and patients are caught in the middle
Dr. Sandra Sleszynski puts her hands on the young patient lying on the exam table and starts working her way over back, shoulders, neck and stomach, gently probing with fingers and with questions:
“How does that feel? You’re not even flinching — good!”
Slezsynski has the girl lie on her side. Then she pulls a leg up with one hand, reaches behind a hip with the other and applies pressure from opposing directions.
Annalise Durrett looks like a human pretzel, but the 14-year-old Lebanon girl says her regular visits to “Doc Sandy” are the only thing that provides relief from the severe pain, dizziness and nausea that have plagued her since a 2010 bout with E. coli ravaged her kidneys and left her unable to walk unaided.
“Usually she’s able to treat each of those while I’m here, and I’m able to leave without that excruciating pain,” she says.
Sleszynski is a Corvallis osteopath, and she has legions of loyal patients who swear by the effectiveness of her osteopathic manipulative treatment, or OMT. But for more than a year now, she and other osteopathic physicians around the state have found themselves assailed by audits from insurance companies that either refuse to pay for the treatment or will only pay at a reduced rate.
The situation has become so burdensome that some osteopaths have stopped doing OMT, opted out of problematic insurance contracts or chosen to retire. Others, including Sleszynski, have stopped billing insurance plans altogether and put their practices on a cash-only basis, forcing some patients to stop coming.
“It’s effectively discrimination,” Sleszynski says.
Under the microscope
Doctors of osteopathy receive the same basic training and face the same licensing requirements as traditional medical doctors in the United States. Unlike MDs, however, DOs also have the option of learning osteopathic manipulative treatment.
OMT aims to promote the body’s natural healing processes by bringing the musculoskeletal system into alignment. The technique is covered by most health insurance policies.
Sleszynski says she never had any problems getting paid for her services until September 2009, when Providence Health Plan audited her clinic, Crossroads Premiere Health Care.
According to Sleszynski, Providence decided she didn’t qualify as a primary care provider because more than half her claims included charges for OMT, and the company dropped her from its network in February 2010.
Two years later, in 2012, Providence audited some of her earlier claims and demanded reimbursement of $72,000, stating that the claims were improperly coded or inadequately supported in patient charts.
Starting in late 2011, other insurance companies also launched audits of Crossroads’ billing practices, including ODS (now renamed Moda) and Regence BlueCross BlueShield of Oregon. Each one required many hours of staff time to respond to records requests and prepare appeals.
“In the last year,” Sleszynski said, “I’ve had six audits that I’ve had to deal with.”
Like Providence, these other companies rejected multiple claims over coding and charting issues.
Medical billing can be extremely complicated these days, but Sleszynski is adamant that her billing practices conform to the standards set out by the American Medical Association in a manual called Current Procedural Terminology. In fact, she’s something of an expert on the CPT — she teaches charting and coding to students at the College of Osteopathic Medicine of the Pacific-Northwest in Lebanon and leads workshops on the subject at medical conferences.
Nevertheless, as a result of the insurance audits, Sleszynski says she’s facing $124,000 in refund demands or unpaid claims. In addition, she estimates she has spent more than $10,000 in attorney fees and $7,100 in staff time battling the audits, as well as untold hours of her own time.
“Small docs are going out of business,” Sleszynski said. “It’s sad because patients aren’t getting care.”
A chorus of complaints
David Walls, executive director of the Osteopathic Physicians & Surgeons of Oregon, started hearing complaints from OPSO members about aggressive insurance audits in late 2011. Most of the complaints involved Regence BlueCross BlueShield or Providence, two of the state’s largest health plans.
The calls just kept coming.
“Throughout 2012, I started hearing more and more complaints from physicians who were being audited and OMT payments being denied,” Walls said.
At a conference in September, he did an informal survey. More than 30 Oregon DOs reported being audited, Walls said — a shockingly high number compared to the three to five calls a year he was used to. A more systematic survey is underway to determine the full extent of the problem and gather information for a possible complaint to the state Insurance Division.
In a large number of cases, claims appear to have been rejected because insurance plans were billed for a high-level patient exam and OMT services in the same visit.
Walls said that’s standard practice for DOs and appears to have been properly reflected in the billing codes by using the number 25 as a modifier of the basic five-digit CPT code. But some insurance companies seem to consider those “bundled” services, which should be billed at a lower rate, and were rejecting the entire claim as a result.
“Those services were provided, they were billed correctly and payments were being denied based on bundling of services,” Walls said.
“I can’t believe everybody suddenly was billing incorrectly,” he added. “It’s either a misunderstanding or a purposeful denial of claims.”
The need for audits
In an age of soaring health care costs, insurers argue that audits are a valuable tool in their efforts to detect deliberate fraud and inadvertent overbilling.
Gary Walker, regional public affairs director for Providence Health & Services, the company that owns Providence Health Plan, denies that the insurer has singled out osteopathic physicians for any additional scrutiny.
“Along with most other health insurers, Providence Health Plan routinely monitors and conducts external audits,” he told the Gazette-Times in an email.
“Our members and customers rely on us to help manage their medical costs,” Walker added. “An important part of that process is ensuring that procedures have been recorded and coded accurately.”
While insurance audits may be routine for all specialties, it seems clear that osteopathic physicians who do manipulation have experienced an increase in audit activity.
The issue extends well beyond Oregon. According to a spokesman for the American Osteopathic Association, similar audits are afflicting osteopathic physicians in all parts of the country.
“DOs who do a lot of OMT are audited probably with more frequency than some other physicians across the country by both public and private payers,” said Dr. Boyd Buser, who sits on the association’s coding committee and serves as dean of a Kentucky osteopathic medical school.
Buser notes that some MD specialists have also complained of surging insurance reviews and thinks the recent wave of audits may have been triggered by automated computer programs set to flag bills that contain the 25 modifier.
A few years ago, the government went after physicians in a wide range of specialties for inappropriately billing Medicare using that code, which is supposed to indicate a significant, separately identifiable evaluation and management service on the same day as a medical procedure. Some doctors were misusing the modifier to overbill the federal insurance program for low-level services, and since then private insurance companies have been giving extra scrutiny to bills coded that way.
“The 25 modifier became a point of emphasis about two years ago,” Buser said. “I think that is most likely what caused (audits) to appear at that point in time.”
A compromise solution
That’s what happened at Regence BlueCross BlueShield, which launched a broad-based audit of osteopathic practitioners across the Northwest after a software program identified potentially problematic billing practices in a sample group in late 2011.
“It was pretty clear there was not adequate documentation to support high levels of coding,” said Dr. Csaba Mera, deputy chief medical director for Cambia Health Solutions, Regence’s parent company. “That’s what triggered the larger audit.”
Of 476 osteopaths in four states who were audited by the insurance company, more than 200 received demands for refunds of claim payments. And as the audits went on, Mera said, the company saw fewer bills with high-level codes and better documentation of the high-level services that were billed.
“At first we were seeing quite a bit of upcoding,” Mera said. “We like to trust the medical community ... but that’s why we do audits.”
At the same time, there was a growing outcry from Oregon osteopaths that insurance audits were becoming increasingly burdensome. As a result, the Osteopathic Physicians & Surgeons of Oregon decided to contact insurers about the situation, starting with Regence.
After a series of meetings with officials of OPSO and the national osteopathic organization, Regence agreed to suspend the audits and refund charges for claim denials and recouped payments. The company is also working to modify some of its procedures for reviewing claims and find ways to make them more “provider-friendly.”
That doesn’t mean there won’t be more audits in the future, Mera pointed out, but for now the company is satisfied that the vast majority of osteopaths it works with are making a good faith effort to code their bills properly and provide adequate documentation.
“It’s our job and it’s our duty to make sure dollars are being spent properly,” Mera said, “but at the same time we want to work with physicians because they’re our partners.”
Patients pay the price
Meanwhile, however, the ongoing billing tussle between osteopaths and insurers is taking a toll on patients.
Since Sleszynski switched to a cash-only practice, some patients have stopped coming altogether. Others, such as Annalise Durrett, have had to cut back on their treatments.
Her mother, Heidi Durrett, now pays cash up front for a $270 office visit and bills her insurance company, which reimburses her for 50 to 75 percent of the cost. Before, when the insurance company was billing Sleszynski’s office directly, all Durrett had to worry about was a $15 copay.
“It definitely affects how often we can be seen because of the cost,” she said. “When we first started to self-bill, we weren’t able to come for three or four months.”
But when she reflects on the progress her daughter has made since beginning the osteopathic manipulative treatments — from a bedridden invalid who couldn’t walk without support to an active teenager who just returned from church camp — Durrett believes the results are worth the expense.
And even though it’s been a hardship for her family, Durrett said she supports Sleszynski and other osteopaths in their fight with the insurance companies.
“I’m really glad this is the route she’s decided to go because I’ve seen my kid come back,” Durett said. “I want everybody to be able to get this kind of care.”
Contact reporter Bennett Hall at email@example.com or 541-758-9529.