The argument for time based billing


Category : Medical Rants

In 2003 (yes this blog is that old) I wrote this piece – Billing like lawyers

Today Bob Wachter tweeted this article – Time-Based Billing: What Primary Care in the United States Can Learn From Switzerland

Time-based billing may offer a simplified payment method that maintains physician autonomy and sense of professionalism. For smaller primary care practices that may not organize into accountable care organizations, time-based claims may offer an alternative means to align payment with meaningful work while simultaneously simplifying documentation and billing. Alternatively, within accountable-care organizations, time-based billing could be used as a physician reimbursement alternative to more common approaches such as volume-based incentives, salary, or pay for performance.

Our current billing processes discourage spending adequate time with each patient.  As I have written repeatedly for the past 14 years, patients need us to spend the proper time attending to their needs.  Time-based billing has made sense for many years, yet the idea never gains traction in the US.  Please read the JAMA Internal Medicine article and let us know what you think.

Comments (7)

Since I HATE anything to do with lawyers and any actual antics they play billing like them skeves me to no end. The shear fact that more time equals more money is counter to the fact that we should be based on helping patients not determined by time clock who pays more. SURE lawyers have justified their “time and materials” approach to billing but then so do plumbers and Rotor Rooter neither of which I feel appropriate assimilating. We need to be paid for experience and expertise and with that if I can answer a problem in 7 minutes as opposed to another who takes 20 does that mean I am to be penalized or should I just sit and chat while running up the clock as we KNOW our lawyers and accountants do with us. The guy who takes a bit longer needs the time to do the job right and shouldn’t just be offered a bonus for being either less knowledgeable or green.
When I first opened my original practice I even had the “privilege” of having my CPA take me to lunch monthly to discuss the financial state of affairs in the practice only to find out that the lunch and the time we spent going over my books was then charged back to me in his invoice. Needless to say he was dismissed and the new one informed that reports needed to be forwarded to me via mail or then email and that discussion over the details would be limited to “as requested” and that any meetings we had would be at my office with time compensation being based on actual time spent not travel and chit chat.
We don’t want to be treated as these 9-5 types lets keep ourselves WAY above the foray of this nonsense and come up with income commensurate to effort, results, and skills.
Dr D

Did you read the JAMA Internal Medicine article?

I stopped reading it after this sentence:
“Under time-based billing with minimal documentation requirements, there is the potential for fraud: physicians could bill for services that were not actually performed.”

Yes, yes, I know that would never happen in Switzerland or here.

But you know what that automatically means? In our system where so much care is reimbursed by the government, it means more oversight, more government organizations, more personnel, higher system costs – all to prevent fraud.

And in the private sector more insurance investigators. More costs unrelated to patient care.

It looks to me, as with so many other Wachterian healthcare suggestions, like another solution to a problem that doesn’t solve the problem but does create new ones.

What about psychotherapy? AFAIK it has always been billed by time. Many mental health agencies pressure time to be exaggerated or outright lied about. Therapists are told to do all charting while in session, which is completely inappropriate and unethical in psychotherapy. Therapists are forced to do med management(which they aren’t really trained for) and bill it as counseling. Although it should be easy to prove based on common sense and chart reviews, reporting such things to state and federal authorities accomplishes nothing.

I’m sure time based billing is a possible solution to many problems, but if it is not handled properly it would be swapping one set of problems for an equal or worse set. I’m convinced that most of the problems with mental health are due to the way that it’s regulated. Obvious abuse is not acted on because it is not a performance measure, while measures with insignificant impact on patient care are magnified.

Like Cory I quit after sentence one. My sister is a Psych and lives her life in “one hour increments” I can’t imagine how much fraud disgruntled patients and shear outright abuse will be created if the system shifts to time billing. I “believe” certain provinces in Canada have Dentistry billed based on time and materials. Each procedure is initially set up as a certain time amount for estimation purposes then once complete the actual time is used to bill the service. What a joke. I can just see me spending 8 hours on a neck dissection and then having to listen to the second surgeon saying “Hey can we stretch it another 20 minutes I got alimony this month”
Why lower ourselves to that nonsense?
Psych’s do it but in reality not the time is set up to be an hour period they don’t lower their rate if the patient says “I am tired lets call it quits” after they go 48 minutes. There is a big difference between billing based on time and booking based on time.
I book office visits based on 4 time slots. People are scheduled for one of 4 time slots then we see them based on first come first served in those slots (no we don’t worry about being behind).
The issue is not HOW we are paid be it salary, commission, per service, incentive, contract, etc the issue is the amount that clears the bank on Friday and the amount we have to put in to get it during the previous 7 days.
We used to be paid for our actions in a fair and reasonable way. Then outsiders decided that looking at the overall society we were paid a disproportionate amount compared to other jobs and industries. SO outsiders altered our compensation. Instead of raising the amount of income other wedges of society made they decided it was easier and better to simply lower our segment. We are SO stupid we actually let them. We are so enamored by the “we are professionals we can’t get involved with fighting for income” that we let them steal our cash.
What SHOULD have happened is we should have raised the GDP and the middle segment of society’s ability to generate income and left us alone. Instead of saying 19% of GDP was too high and then raise GDP we took the defeatist approach and said we can’t make the economy better because we already give 35% of American’s hand outs so there is no incentive to work so lets just steal it from those with a good work ethic and all will be OK
The issue is that the current generation coming out of med school are NOT going to put in 110 hour work weeks are not going to allow double resident shifts like we did. They are not going to do more for less like we have and when the phone rings at 3AM they will simply respond with “take the patient to the ED” or if it is a nurse calling the response will be “call the hospitalist”
EVERY action has a reaction in this case society has not yet seen the final reaction and when they do they will not like it and yet there will be NO way to return to “the good old days”
Dr D

The easiest visits to code, and the ones that produce a note that’s more about patient care than checking meaningless boxes, are my time based billing visits.

I wish all my visits could be that way.

ANY billing system can be gamed, fraud will occur in any system. How else do we get 5 page notes in a 10 minute visit when paid for documentation? The current system gives an incentive to take care of the paperwork rather than the patient.

Concerns about fraud currently leads to torture on the RAC, there will nevermore be a system without bureaucratic oversight. As Thomas Sowell states, “There are no solutions, only tradeoffs”.

In any case, changes need to be tested adequately before widespread adoption.

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