By Peter Dehnel, MD
Imagine having a drive-up window at your clinic where patients can simply come at any time of the day or night, discuss their medical concerns, get your recommendations for care, get a prescription or some of their services coordinated with medical specialists, and then are sent on their way without charging a penny. Unthinkable, isn’t it? In this day of drive-up services, ease of credit card payments at fast food restaurants, and McDonald’s Big Macs, many products and services come with a definable price. As a result, people are more than willing to pay for them. So why should individualized medical advice be any different?
Consider the equivalent situation where, instead of a drive-up window, a nurse or doctor simply substitutes in-person care with care delivered over the telephone. A valuable service is provided, care recommendations are given, a prescription is called in, or assistance with coordinate care with specialists is arranged. Most medical providers will end up not charge anything. Most clinics don’t even have a process to recoup some of their telephone care costs, even when it is costing them several thousand dollars a year to give this care away free on the phone.
Telephone care and advice has been around, literally, for over a hundred years. Most patients consider it as part of their standard relationship with a clinic. This is especially true if they have a question they feel does not require a face-to-face interaction with a clinician. More significantly, most insurers consider it as a standard inclusion in their contracts with clinics and not as a separate “episode of care,” which is then a billable service.
There are an expanding number of reasons why it is important for all clinicians to rethink this paradigm and consider charging for medical care that is delivered in non-face-to-face settings. It is individualized patient care that you are providing to an established patient. Just as you would not charge an office visit if you have a casual hallway conversation in your office with a patient, you only charge for telephone calls that have some element of medical decision-making.
Telephone care, when it is considered as a part of total patient care, has a number of advantages to both the patient and the clinician. It is providing care to the patient that is more convenient and in a timeframe that meets their needs and availability. These care encounters will likely cost the patient less, since the cost for these visits will likely be less than the standard office visit. Since these have the additional advantage of not requiring the patient to come to an office, they do not have the indirect costs of missing work, driving to the clinician’s office, parking, and so forth.
For the clinic, telephone care will free up appointment times to see the patients that truly need to be seen in person. They will allow a broader number of options for follow-up care. Since these calls have to meet all of the documentation requirements of an office visit, the clinician will do a better job of documenting the telephone encounter. This will give a more complete picture in their medical record, will likely provide better coordination of care for patients with chronic conditions, and will reduce legal liability issues related to undocumented care and advice. Since a certain number of these calls will happen anyway, clinics will recoup some of the cost of delivering this care that has previously been missed.
The American Academy of Pediatrics has recently issued a policy statement supporting payment for telephone care (“Payment for Telephone Care.” Pediatrics 2006;118(4):1768-1773). This had been preceded by a 2003 policy statement by the American College of Physicians endorsing payment for telephone care. In addition, some insurers are now reimbursing for “e-visits” – non face-to-face care encounters delivered over the Internet.
For those clinics and clinicians who want to venture into this new territory, preparation is the key to a successful outcome. You will need to develop a clinic process that includes fairly explicit descriptions of what type of calls will be included, the basis of charging for them, the documentation requirements and any supporting forms, how billing will be accomplished, and what to do with patient complaints and insurance denials. Your patients will have to be notified well in advance in a number of different ways, and options to come in for a real face-to-face visit may have to be available on a real-time basis. Finally, forewarning the insurers is always a good idea, and you will need to determine what appeal options for non-reimbursement are available to you.
Medical care over the phone is a great option for patients and clinicians. There is no reason why it should supplied free of charge in a haphazard way. It is time for clinicians to think about this type of care in a new way. This is especially true in light of the fact that the options for non face-to-face interactions are expanding much faster than we can currently accommodate.
Peter Dehnel, MD, is the Medical Director for Children’s Health Network and the Medical Director for Children’s Health Network Triage Service, Minneapolis, MN.
[From the August/September 2007 issue of AnswerStat magazine]