PEDIATRICS Vol. 101 No. 4 April 1998, p. e2

ELECTRONIC ARTICLE:
Telephone Charges and Payments in a Diabetes Clinic

John L. Kirkland and Kenneth C. Copeland

From the Department of Pediatrics, Baylor College of Medicine, Houston, Texas.

	ABSTRACT

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Objectives.  To determine reimbursement rates after initiation of charges for certain telephone calls in a pediatric diabetes care center.

Design.  A review of charges and payments data during 1996.

Results.  Four hundred seventy-two telephone calls initiated by patients and parents were billed during the study period. These calls regarded treatment of hypoglycemia, hyperglycemia, ketonuria, sick day treatment, and insulin dose changes. Insured patients were charged for 384 telephone calls and indigent patients were charged for 88 telephone calls. Telephone calls from insured patients generated charges of $9215 and payments of $3074. Insurance payments were $1677 (18% of charges), and patient payments were $1396 (15% of charges). Telephone calls from uninsured patients covered by Texas Medicaid or Chronically Ill and Disabled Children funding generated charges of $2193 and no payments.

Conclusions.  Telephone charges were reimbursed by all payors at an overall rate of 27%.

	INTRODUCTION

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Current standards of diabetes mellitus (DM) treatment require frequent and intensive contacts between patients and health care providers.¹ The majority of this contact is provided by telephones in most diabetes treatment centers. Patients obtain advice regarding the treatment of hypoglycemia, hyperglycemia, ketonuria, and insulin dosage adjustments, as well as advice related to social or psychological issues. Medical treatment provided primarily by telephones reduces emergency center visits and hospital admissions.² Charges generated and payments received for telephone calls as a part of the medical treatment of children with DM have not been reported previously. The following study was designed to determine the reimbursement rates for telephone charges in the Diabetes Care Center (DCC) at Texas Children's Hospital.

	MATERIALS AND METHODS

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The DCC at Texas Children's Hospital recorded 2910 outpatient visits for over 1000 children with DM during 1996. Patients and parents were informed in October 1995, by a DCC newsletter and posters in the DCC that charges would be made for certain telephone calls to nurse educators and physicians starting January 1996. One of the authors (J.K.) met with state Medicaid officials explaining the need for telephone calls and charges in the treatment of children with DM. Medicaid officials stated that charges for telephone calls from Medicaid patients or parents would not be reimbursed. Insurance companies were not notified prospectively of our anticipated charges because telephone codes were included in their Current Procedural Terminology (CPT) codes. Physicians and diabetes nurses providing telephone treatment were unaware of the patients' insurance status, financial status, or previous history of payments. Criteria were established prospectively for charges. These criteria included the need to document the event in the medical record and the complexity of the problem. All medical care rendered by diabetes nurse educators required physician review, agreement, and signature on written reports. Charged calls included such problems as sick day treatment in moderately ill children, complicated insulin adjustments, severe hypoglycemic episodes, insulin regimens for lengthy airline flights, and major social problems affecting diabetes care. Simple questions involving routine insulin dose adjustments, prescription refills, and requested call backs were not charged. In addition, charges were not generated for newly diagnosed patients until the parents completed an advanced skill class addressing self-treatment of sick days and insulin dosage adjustments. Charges were not made for questions pertaining to insulin pump treatment.

CPT codes used for charging were 99371 at $20, 99372 at $50, and 99373 at $95. CPT 99371 codes were for specific problems such as insulin adjustment through pattern treatment. CPT 99372 codes were for expanded problems such as sick day treatment involving multiple contacts. CPT 99373 codes were used for comprehensive problems such as insulin and feeding schedules for transcontinental airline travel. Ninety-two percent of the calls were 99371 codes, 6.7% were 99372 codes, and 1.3% were 99373 codes. The telephone calls were grouped for analysis. Seventy-six percent of the calls regarded insulin dosage adjustments for any reason, 19% regarded sick day treatment, and 5% regarded hypoglycemia, intercurrent illnesses, travel plans, and social problems. The mean duration of all telephone calls was 17.6 minutes, with a standard deviation of 9 minutes.

An agreement was made with the billing office that collections would not be pursued through collection agencies if payments were not received during the trial period. Charges and revenues generated from these telephone calls were composed using an database management systems query in IDX software on a DEC computer. The specific billing information was downloaded to an Excel spreadsheet for further analysis. Qualified indigent patients in Texas receive financial assistance through Texas Medicaid and Chronically Ill and Disabled Children (CIDC) funding. Insured patients receive financial assistance through their health maintenance organization, or fee-for-service plans. The DCC enrollment figures indicated 18% indigent and 82% insured patient visits during 1996. Reimbursement rates for all DCC charges were 65% for insured patients, and 25% for indigent patients during 1996.

	RESULTS

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The results are indicated in Table 1. Four hundred seventy-two telephone calls were billed. Indigent patients were billed 88 times, or 19% of total charged calls. Insured patients were billed 384 times, or 81% of total charged calls. Charges for the indigent patients were $2193 or 19% of total charges. Charges for the insured patients were $9215 or 81% of total charges. No payments were received from Texas Medicaid or CIDC. Payments from insured patients were $3074 or 33% of charges. Personal payments (noninsurance) from the insured patients were $1397 or 15% of charges, while insurance payments were $1677 or 18% of charges. Eighteen insurance companies, excluding Medicaid and CIDC, were billed during this period. Four insurance companies did not reimburse any charges. Fourteen of the insurance companies reimbursed charges submitted at 26%. Co-payments for charges submitted to the parents were reimbursed at 54%.

	CONCLUSIONS

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Several reports indicate the importance of telephone calls in managing pediatric patients.⁵ Telephone contact with patients was an integral component of the successful outcomes in The Diabetes Control and Complications Trial¹. The use of the telephone permits patients and parents an opportunity to receive complex medical care without an appointment, without compensation to those delivering the medical care, and avoids other inconveniences inherent in emergency room or clinic visits. Medical care administered by telephone in our DCC previously has been without charges, and available 24 hours per day. Five board-certified pediatric endocrinologists and three nationally certified diabetes nurses provided medical care by telephone. It is noteworthy that the additional personnel, time, and cost required to provide such medical care to this population of chronically ill patients by telephone have not been reported previously. The DCC at Texas Children's Hospital receives approximately 20 telephone calls per day from diabetic patients. These calls range from acute medical emergencies to nonurgent insulin prescription refills. In our DCC, approximately 1 full-time equivalent, a highly skilled diabetes nurse, must devote 100% of effort to meet the telephone needs of approximately 1000 children with diabetes mellitus during usual office hours.

Proposed guidelines from state Medicaid and current health maintenance organization contracts dictate close patient-provider contact, including telephone response time for covered patients.^9,10 The poor financial reimbursement for these services suggests that third-party payors have an inadequate appreciation for both the costs to providers as well as the necessity of telephone contacts for adequate medical treatment of such complex patients. DM represents a prime example of a chronic disease where constant vigilance reduces medical costs.¹ The results of the current study likely pertain also to a wide variety of chronic pediatric diseases, such as cystic fibrosis, cancer, and asthma where close telephone contact may reduce clinical complications.

We conclude that telephone contacts for complex and emergency care of children with DM are reimbursed poorly by most third-party payors and none by others despite their proven benefits.^1,5,6 This low reimbursement rate at our DCC may have been increased through a more aggressive approach toward collections. The increasing emphasis on health care cost containment at this DCC suggests that telephone treatment may not survive future reductions in reimbursements.

	FOOTNOTES

Received for publication Sep 8, 1997; accepted Jan 6, 1998.

Address correspondence to: John L. Kirkland, MD, Department of Pediatrics, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030.

	ABBREVIATIONS

DM, diabetes mellitus. DCC, Diabetes Care Center at Texas Children's Hospital. CPT, Current Procedural Terminology. CIDC, Chronically Ill and Disabled Children.

	REFERENCES

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1. The Diabetes Control and Complications Trial Research Group The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993; 329:977-986[Abstract/Free Full Text]
2. Evans S, Curtis P, Talbot A, Baer C, Smart A Characteristics and perceptions of after-hours callers. Fam Pract. 1985; 2:10-16[Abstract/Free Full Text]
3. Bertera EM, Berta RL The cost-effectiveness of telephone vs clinic counseling for hypertensive patients: a pilot study. Am J Public Health. 1981; 71:626-629[Abstract/Free Full Text]
4. Wasson J, Gaudette C, Whaley F, Sauvigne A, Baribeau P, Welch HG Telephone care as a substitute for routine clinic follow-up. JAMA. 1992; 267:1788-1793[Abstract]
5. Narayan K Cost-effectiveness of intensive insulin therapy in the diabetes control and complications trial. JAMA. 1997; 277:374-375[CrossRef][Medline]
6. The Diabetes Control and Complication Trial Research Group Lifetime benefits and costs of intensive therapy as practice in the diabetes control and complications trial. JAMA. 1966; 276:1409-1415
7. Sorum PC, Mallick R. Physicians' opinions on compensation for telephone calls. Pediatrics. 1997;99(4). URL: http://www.pediatrics.org/cgi/content/full/99/4/e3
8. Sorum PC Compensating physicians for telephone calls. JAMA. 1994; 272:1949-1950[CrossRef][Medline]
9. Herter C, Hirsch I. Diabetes and managed carethe reality. Pract Diabetol. 1994;(December):2-6
10. Quickel K. Diabetes in a managed care system. Ann Intern Med. 1966;124(No 1, Part 2):161-163