This is a long one, but worth reading.  The names have been changed to protect both the innocent and the guilty.

The story begins with a clever pediatric practice who decides that since Insurance Company A (we'll call them Cygnus to keep it short) does not want to pay for the 99051 code, it will send Cygnus patients to the ER or have them sign and fulfill the following waiver:

Clever 99051 Waiver

This waiver was pre-empted by the following letter from the practice too all Cygnus patients:

Warning Letter

There are a few things that I really like about the waiver and the letter, but note that great paragraph about cost-shifting.  I plan to steal, er, share it.   Note that I've removed identifying information from the letter, that part isn't important.

To no surprise, a patient called about the letter to complain.  Cygnus wrote to the practice.  Things start to get interesting here:

Our Sales department received the attached letter from a few concerned Cygnus Customers (your patients). It appears that the information noted is a little misleading. Cygnus does and have always covered specific after hour codes. Code 99051 has been set to deny since June 2008. We cover code 99050 & 99058. After running a report on pediatric groups in the Eastern Carolina, code 99050 & 99058 are the only codes they bill for after hour services. Please advise why your office can not bill with either of these covered codes?

Also, please explain your option # 3 listed on your letter. Why would you charge our Customers an additional $36 for services when there is a more appropriate billing code? Per your contract you should only bill patients for there coinsurance/copay and deductible.

Also, Section 5.8, Use of Name, in your contract agreement states the following:

*Group's and its Represented Providers' use of Cygnus' name or a Cygnus Affiliate's name, or any other use of Group's and its Represented Providers' name by Cyngus will be upon prior written approval or as the parties may agree.*

In addition our Sales department is educating our Customers to help them understand that we do cover other after hour codes.

Bam, insurance speak!  "...always covered specific after hour codes."  The problem here is that the code Cygnus covers is not appropriate for the service performed.  Right there in the letter, the insurance company suggests that there is a "more appropriate billing code" for the procedure when, in fact, there is not.

But then it gets weirder.   They go on to claim that the practice is not allowed to refer to the insurance company in any of its patient communication without written approval.  Crazy!  Talk about restraint of trade!  Clearly, that's not the least bit enforceable, but we've got the low level account managers buying it full form.

The practice didn't back down, however.  The practice president wrote back:

I am the President of Children's Clinic. I appreciate you taking the time to respond to an insured's complaint. Children's Clinic has offered office hours on Saturday and Sunday since the 60's - over 40 years! During this time, we have always charged an extra charge to the patient for being seen in our office on the weekend and holidays.  A couple of years ago, there was a shuffling of the CPT codes used to describe the added work of seeing patients on the weekend, and we shifted from 99050 to 99051. See the standard definitions below:

CPT 99050

Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (eg, holidays, Saturdays or Sunday) in addition to basic service.

CPT 99051

Services provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to the basic service.

Our weekend hours are posted and known by our patients - 8:30 -12 Saturday and 12-4p Sunday. Although our hours are not "regular" in that we do not pre-schedule, we do not allow the patient to pick which physician they see, and we do not see non-urgent problems (Well child care, ADHD follow-up, Behavior problems, etc), we switched to the newer code, 99051, thinking that was the closest "fit" to what we do.

Our policy is that we do not see patients without the extra revenue in our office on the weekends. If an insurance company would rather their clients be seen in a MUCH more expensive ER, then we are happy to make the referral. Even NC Medicaid pays for the 99051 code. Our charge for 99051 is $36. Even with the added charge, we feel we are much more cost effective than the ER and thus are confused as to why a company would prefer their patients be sent away -- but insurance companies often display confusing logic.

We have been paid by Cygnus (on appeal) for the 99051 code until this past January when the appeals were no longer allowed/honored. We were not notified prior to the change, which I think could be a violation of our contract. We subsequently notified our patients who appeared to be insured by Cygnus. Attached is a copy of the text of the letter that we sent to your insureds.

As a separate issue, I must admit I am confused by your reference to Section 5.8 where we are not supposed to use your name without permission. BCBS has the same clause and they explained it only pertained to public use - like in a newspaper ad. The letter we sent was addressed specifically to the few patients we have insured by Cygnus and by no means was it "public". We also print the name of the insurance company of each patient on the bottom of the Encounter Form which is given to the patient as a copy of their visit. I suppose we could replace the proper spelling of your company's name, but again, this seems quite silly. Perhaps not as silly as referring your insureds to the local ER to "save" money, but nonetheless, silly. Please send clarification of Section 5.8. I assume we cannot use it in public venues such as newspapers or web pages, but I would like clarification if we can use the word in spoken and written communication with patients insured by you.

If your company would like for us to use 99050 for weekend visits, we would be happy to do so and that could solve this entire mess. 99050 is the code we have used for years until the newer 99051 came out. To avoid the possibility of future accusations of insurance fraud by others in your company, please send me an email or letter stating something clear like :

"Children's Clinic is known by us to have predictable and advertised limited office hours on Saturdays and Sundays. We recognize this is a service to our patients as well as a cost savings to us and are willing to pay an extra amount in addition to the usual E&M codes.  We have asked CCC to use the code 99050 instead of 99051 so that we may pay appropriately."

Of course, the 99051 should be comparable to what we have been paid in the past. We would of course rather see out patients than have our local emergency room procedure them to pieces - but we will not violate out long standing policy to accommodate your creative bundling of the 99051 into the usual E&M codes. Either way, this will only affect a small number of patients.

So, he called them out. "Sure, I'll use the inappropriate 99050 code...just give me your permission in writing." Anyone want to guess what happened next?