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Ask the Expert
| Author: Dr. Sheila Dunn |
| Article Date: 2/1/2007 |
Ask the Expert Feb 2007
In our Ask the Expert column, Dr. Sheila Dunn (AKA Dear Labby) dishes out accurate, concise and, sometimes, hilarious answers to your concerns about diagnostic testing, regulations and reimbursement for the physicians office. So, come on……ask the expert! Email your questions to andyfillin.com
Screening Test Payments
Q. With all the emphasis on early detection and treatment nowadays, why aren’t preventive/screening tests such as EKGs, eye exams, cholesterol tests, and the like reimbursed consistently?
A. Until recently, Medicare hasn’t practiced what it preaches about preventive health, and maintained that covered tests must be medically necessary. That’s legalese for “if someone doesn’t have obvious symptoms of a disease, Medicare won’t pay for a test to diagnose it”! This ludicrous rule caught the attention of several prestigious groups who also noticed the discrepancy between what is said (“you really need to get screened for heart disease”) versus what is covered (“but you’ll have to pay for it out of pocket”).
So, Medicare anted up to cover some, but certainly not all preventive testing.
Medicare Lab Test Screening Coverage
Additional screening tests are also covered, but they are referred out and payable under the physician fee schedule: pap smears (all female beneficiaries, once every two years; those at high risk, annually); colonoscopy (once every two years for all beneficiaries, no minimum age limit); flexible sigmoidoscopy (once every four years); and barium enema as alternative to either.
Finally, Medicare will pay for screening EKGs and eye exams separately under the Welcome to Medicare exam.
Carpet in Exam Rooms
Q. My partner and I are moving to a new office building and she insists on installing carpet in the exam rooms. She thinks the aesthetic value of carpet outweighs the fact that it could be contaminated with patient body fluids. I disagree. Is there a law I can cite to get her to change her mind?
A. Its fine to have carpet in exam rooms, if patients don’t take off their clothes, get injections or inadvertently lose their cookies during a visit! Unless you specialize in psychiatry or chiropractic, expect the occasional accident, and steer clear of carpet in clinical areas.
It’s not an OSHA violation to carpet an exam room – BUT- OSHA does require complete disinfection of carpet after every instance of contamination with patient blood or body fluids. Imagine cleaning that carpet with a disinfectant, such as 10% bleach….in time, that carpet will look like a Jackson Pollack print! That’s why virtually all medical practices have moved away from carpeted exam rooms.
With that said, OSHA is concerned only with employee safety, not patient safety, so unless employees are running around in their bare fee, OSHA wouldn’t issue a fine for gross carpet.
Here’s a compromise, though, if your partner continues to insist on carpet in patient procedure areas, use cheap oriental area rugs with a non-slip backing over a tiled surface. A rug with a nice burgundy background and an intricate pattern helps to keep blood and body fluid barely noticeable! And, when the rug becomes unsightly, all you have to do is make one trip down to “Cheap Charlie’s World of Rugs” for a replacement. Be sure to throw out the old rug in the red bag, though!
Where NOT To Put Sharps Containers
Q. A colleague of mine told me that their practice was cited for mounting a sharps container behind the cabinet door under a sink. Our practice keeps sharps containers under sinks too, to keep people, especially children, from injuring themselves. What law does this violate?
A. Lots of doctors’ offices tell me about drug addicts that steal from the sharps boxes and kids who climb the walls to poke their little fingers in the sharps containers while mom is whistling Dixie. To me, this is a perfectly acceptable way to add some chlorine to our proverbial gene pool, but alas, most medical practices don’t agree. Placing sharps containers inside sink cabinets is reasonable from a patient safety standpoint, but OSHA begs to differ. OSHA’s concern is “worker” safety.
OSHA’s Bloodborne Pathogens Standard [1910.1030(d)(4)(iii)(A)(2)] says that sharps containers must be: 1. Easily accessible to personnel (i.e., within arm’s reach of the procedure), and 2. Maintained upright through use (i.e., not placed where they could be knocked over).
Placing sharps containers inside a cabinet violates the first provision above; since it’s likely a worker could be injured when trying to maneuver a sharp object dripping with blood into such a container. Other unacceptable areas to place sharps containers include:On the backs of room doors
In areas where people may sit or lie near the container (e.g., directly over the exam table)
Near light switches or thermostats
Any other area where the sharps container could be accidentally hit or dislodged by a person, moving equipment, wheelchairs or swinging doors.
Marking Up Referral Lab Tests
Q. Exactly when is it not kosher to mark up the price of tests that we send to a referral lab?
A. For Medicare patients, marking up tests that were performed in another lab is illegal. Direct billing is a part of Medicare law, which says that only the lab that performs a test can bill Medicare. For non-Medicare payers, direct billing is a requirement only in California, Iowa, Louisiana, Montana, Nevada, New Jersey, New York, South Carolina and Rhode Island. Many managed health plans have begun to deny claims where send-out tests are marked up too, especially after a sensational story in the Wall Street Journal Times entitled “How Some Doctors Turn a $79 Profit From a $30 Test”
HIV Tests for All Pregnant Women
Q. Our OBGYN group is considering offering HIV tests in-house, now that the US Preventive Services Task Force recommends screening all pregnant women for HIV. How many CLIA waived HIV test kits are on the market? How profitable are they?
A. There are at least two rapid, CLIA waived HIV tests that provide results during the patient visit with about 99% accuracy.
The Medicare fee cap for CLIA-waived rapid HIV test kits using CPT 86703QW is $19.17, but not many Medicare patients (over 65), need to be tested. Medicare payment amounts are benchmarks for private payers, though, so managed plan should pay near the Medicare fee cap. Although you won’t go to the poor house offering these tests, you won’t make much of a profit either. Rapid HIV tests cost about $15.
Cost Saving Tip
Q. With the increased cost of doing business and ever declining reimbursement for office visits and tests, I thought readers would appreciate hearing about a little cost savings: instead of buying expensive biohazard spill kits, we use kitty litter. We have over 20 locations where spill kits are kept and have saved a lot of money. Cool, huh?
A. For every person with a spark of genius, there are a hundred with ignition trouble. Kitty litter makes a wonderful “absorbent” component of a homemade spill kit, except for two little problems. Commercial spill kits have an expiration date, when the absorbent powder no longer functions to draw up liquid. I’ve never seen an expiration date on kitty litter (but then I’ve never looked for one either!), so you’ll only find out that the kitty litter is kaput when an employee drops a whole tray of blood tubes! The second problem is that by the time someone has driven to Piggly Wiggly and back, opened the bag and poured litter into little zip-lock bags, then combined it with a scoop, disinfectant and gloves, they’ve just spent lots more than what it would have cost to buy a spill kit.
Finally, picture this. A patient whose derriere is indelicately protruding from the back of one of those scratchy paper gowns notices a big bag of “Purrrfect Step” cat litter….Do you think he would you have reservations about trusting the doc with his new incontinence problem? Nuff said. Thanks for sharing.
Getting Managed Care Plans to Pay For a New Test
Q. I’ve switched from the old fecal occult blood test to the new immunochemical one (iFOBT), since it works better to detect colon cancer and reimburses much more from Medicare. Some managed care plans, however, don’t accept the new CPT code. How can I get a managed care plan to recognize and pay for the new test?
A. You hit the nail right on the head; the situation you described happens every time new CPT codes are created. Most managed care plans seize the opportunity to drag their feet paying for new codes. In rare cases, managed care plans will disagree with Uncle Sam’s new screening recommendations and not pay at all.
At least one iFOBT manufacturer (Beckman Coulter) provides a customized letter to send to the managed care company to convince them to add the new code and to pay at least what Medicare pays. The letter clearly states why the managed care plan should pay $22 for an iFOB test rather than $3.50 for the old one (Hint: the new one actually detects colon cancer rather than last night’s steak!). To get results fast, have all physicians in your group sign the letter and copy everybody and their brothers (including the state medical society) on the letter.
Mercury Bans
Q. One of the hospitals in our city just announced that they’ve made the switch away from mercury-containing devices. Has a new federal law passed?
A. No, but several states and local ordinances ban mercury thermometers and sphygmomanometers, The Making Medicine Mercury Free report states that in the last 10 years, over 97% of surveyed hospitals had taken steps to reduce mercury. Eighty percent of survey respondents had completely eliminated mercury thermometers, 73% had completely eliminated mercury sphygmomanometers, and 75% had completely eliminated other mercury items such as cantor tubes. To see which states and localities have mandated mercury elimination, see http://www.hcwh.org/mercury/ordinances.
In our Ask the Expert column, Dr. Sheila Dunn (AKA Dear Labby) dishes out accurate, concise and, sometimes, hilarious answers to your concerns about diagnostic testing, regulations and reimbursement for the physicians office. So, come on……ask the expert! Email your questions to andyfillin.com
Screening Test Payments
Q. With all the emphasis on early detection and treatment nowadays, why aren’t preventive/screening tests such as EKGs, eye exams, cholesterol tests, and the like reimbursed consistently?
A. Until recently, Medicare hasn’t practiced what it preaches about preventive health, and maintained that covered tests must be medically necessary. That’s legalese for “if someone doesn’t have obvious symptoms of a disease, Medicare won’t pay for a test to diagnose it”! This ludicrous rule caught the attention of several prestigious groups who also noticed the discrepancy between what is said (“you really need to get screened for heart disease”) versus what is covered (“but you’ll have to pay for it out of pocket”).
So, Medicare anted up to cover some, but certainly not all preventive testing.
Medicare Lab Test Screening Coverage
Additional screening tests are also covered, but they are referred out and payable under the physician fee schedule: pap smears (all female beneficiaries, once every two years; those at high risk, annually); colonoscopy (once every two years for all beneficiaries, no minimum age limit); flexible sigmoidoscopy (once every four years); and barium enema as alternative to either.
Finally, Medicare will pay for screening EKGs and eye exams separately under the Welcome to Medicare exam.
Carpet in Exam Rooms
Q. My partner and I are moving to a new office building and she insists on installing carpet in the exam rooms. She thinks the aesthetic value of carpet outweighs the fact that it could be contaminated with patient body fluids. I disagree. Is there a law I can cite to get her to change her mind?
A. Its fine to have carpet in exam rooms, if patients don’t take off their clothes, get injections or inadvertently lose their cookies during a visit! Unless you specialize in psychiatry or chiropractic, expect the occasional accident, and steer clear of carpet in clinical areas.
It’s not an OSHA violation to carpet an exam room – BUT- OSHA does require complete disinfection of carpet after every instance of contamination with patient blood or body fluids. Imagine cleaning that carpet with a disinfectant, such as 10% bleach….in time, that carpet will look like a Jackson Pollack print! That’s why virtually all medical practices have moved away from carpeted exam rooms.
With that said, OSHA is concerned only with employee safety, not patient safety, so unless employees are running around in their bare fee, OSHA wouldn’t issue a fine for gross carpet.
Here’s a compromise, though, if your partner continues to insist on carpet in patient procedure areas, use cheap oriental area rugs with a non-slip backing over a tiled surface. A rug with a nice burgundy background and an intricate pattern helps to keep blood and body fluid barely noticeable! And, when the rug becomes unsightly, all you have to do is make one trip down to “Cheap Charlie’s World of Rugs” for a replacement. Be sure to throw out the old rug in the red bag, though!
Where NOT To Put Sharps Containers
Q. A colleague of mine told me that their practice was cited for mounting a sharps container behind the cabinet door under a sink. Our practice keeps sharps containers under sinks too, to keep people, especially children, from injuring themselves. What law does this violate?
A. Lots of doctors’ offices tell me about drug addicts that steal from the sharps boxes and kids who climb the walls to poke their little fingers in the sharps containers while mom is whistling Dixie. To me, this is a perfectly acceptable way to add some chlorine to our proverbial gene pool, but alas, most medical practices don’t agree. Placing sharps containers inside sink cabinets is reasonable from a patient safety standpoint, but OSHA begs to differ. OSHA’s concern is “worker” safety.
OSHA’s Bloodborne Pathogens Standard [1910.1030(d)(4)(iii)(A)(2)] says that sharps containers must be: 1. Easily accessible to personnel (i.e., within arm’s reach of the procedure), and 2. Maintained upright through use (i.e., not placed where they could be knocked over).
Placing sharps containers inside a cabinet violates the first provision above; since it’s likely a worker could be injured when trying to maneuver a sharp object dripping with blood into such a container. Other unacceptable areas to place sharps containers include:
Marking Up Referral Lab Tests
Q. Exactly when is it not kosher to mark up the price of tests that we send to a referral lab?
A. For Medicare patients, marking up tests that were performed in another lab is illegal. Direct billing is a part of Medicare law, which says that only the lab that performs a test can bill Medicare. For non-Medicare payers, direct billing is a requirement only in California, Iowa, Louisiana, Montana, Nevada, New Jersey, New York, South Carolina and Rhode Island. Many managed health plans have begun to deny claims where send-out tests are marked up too, especially after a sensational story in the Wall Street Journal Times entitled “How Some Doctors Turn a $79 Profit From a $30 Test”
HIV Tests for All Pregnant Women
Q. Our OBGYN group is considering offering HIV tests in-house, now that the US Preventive Services Task Force recommends screening all pregnant women for HIV. How many CLIA waived HIV test kits are on the market? How profitable are they?
A. There are at least two rapid, CLIA waived HIV tests that provide results during the patient visit with about 99% accuracy.
The Medicare fee cap for CLIA-waived rapid HIV test kits using CPT 86703QW is $19.17, but not many Medicare patients (over 65), need to be tested. Medicare payment amounts are benchmarks for private payers, though, so managed plan should pay near the Medicare fee cap. Although you won’t go to the poor house offering these tests, you won’t make much of a profit either. Rapid HIV tests cost about $15.
Cost Saving Tip
Q. With the increased cost of doing business and ever declining reimbursement for office visits and tests, I thought readers would appreciate hearing about a little cost savings: instead of buying expensive biohazard spill kits, we use kitty litter. We have over 20 locations where spill kits are kept and have saved a lot of money. Cool, huh?
A. For every person with a spark of genius, there are a hundred with ignition trouble. Kitty litter makes a wonderful “absorbent” component of a homemade spill kit, except for two little problems. Commercial spill kits have an expiration date, when the absorbent powder no longer functions to draw up liquid. I’ve never seen an expiration date on kitty litter (but then I’ve never looked for one either!), so you’ll only find out that the kitty litter is kaput when an employee drops a whole tray of blood tubes! The second problem is that by the time someone has driven to Piggly Wiggly and back, opened the bag and poured litter into little zip-lock bags, then combined it with a scoop, disinfectant and gloves, they’ve just spent lots more than what it would have cost to buy a spill kit.
Finally, picture this. A patient whose derriere is indelicately protruding from the back of one of those scratchy paper gowns notices a big bag of “Purrrfect Step” cat litter….Do you think he would you have reservations about trusting the doc with his new incontinence problem? Nuff said. Thanks for sharing.
Getting Managed Care Plans to Pay For a New Test
Q. I’ve switched from the old fecal occult blood test to the new immunochemical one (iFOBT), since it works better to detect colon cancer and reimburses much more from Medicare. Some managed care plans, however, don’t accept the new CPT code. How can I get a managed care plan to recognize and pay for the new test?
A. You hit the nail right on the head; the situation you described happens every time new CPT codes are created. Most managed care plans seize the opportunity to drag their feet paying for new codes. In rare cases, managed care plans will disagree with Uncle Sam’s new screening recommendations and not pay at all.
At least one iFOBT manufacturer (Beckman Coulter) provides a customized letter to send to the managed care company to convince them to add the new code and to pay at least what Medicare pays. The letter clearly states why the managed care plan should pay $22 for an iFOB test rather than $3.50 for the old one (Hint: the new one actually detects colon cancer rather than last night’s steak!). To get results fast, have all physicians in your group sign the letter and copy everybody and their brothers (including the state medical society) on the letter.
Mercury Bans
Q. One of the hospitals in our city just announced that they’ve made the switch away from mercury-containing devices. Has a new federal law passed?
A. No, but several states and local ordinances ban mercury thermometers and sphygmomanometers, The Making Medicine Mercury Free report states that in the last 10 years, over 97% of surveyed hospitals had taken steps to reduce mercury. Eighty percent of survey respondents had completely eliminated mercury thermometers, 73% had completely eliminated mercury sphygmomanometers, and 75% had completely eliminated other mercury items such as cantor tubes. To see which states and localities have mandated mercury elimination, see http://www.hcwh.org/mercury/ordinances.