Third-Party Payment Matters
This is from Dr. Rich of The Covert Rationing Blog via Jason Shafrin:
In a survey…published in the April 12, 2000, issue of the Journal of the American Medical Association, 39% of American doctors admitted that they sometimes or very often manipulated reports to their patients’ health plans so their patients might gain coverage for needed medical care. These manipulations included exaggerating the severity of the patients’ condition, changing the billing diagnosis, or reporting symptoms the patient did not have. And 72% admitted using one of these tactics at least once in the past year. More than a quarter said that gaming the system was necessary in order to provide high quality care to their patients, and 15% asserted that it was ethical….
Another survey, published in the July/August, 2003, issue of Health Affairs, reported that nearly 33% of American doctors admit that they routinely withhold from their patients pertinent information about optimal medical treatments, because they suspect the patients’ health plans won’t cover those treatments.
Doctors and patients manipulating reimbursement formulas. What else is new?
There are consulting firms that specialize in maximizing revenue by up coding when the diagnosis is borderline between two codes. This is legitimate when done honestly. But there is a fine line between honesty and aggressive up coding where your strategy is to push the limits while avoiding charges of outright fraud.
Agree with Bruce. No surprise here.
Do random audits and impose heavy fines and perhaps a short stint in jail. There’s an old Chinese saying about killing a chicken in front of the monkeys.
artk, put doctors in jail for helping their patients get medical care they can afford? Whose side are you on?
If 39 percent of physicians are misleading the health plans with which they are contracted, and 39 percent of physicians are misleading the patients whom they consult, then only 22 percent are acting in good faith towards both of those parties!
“Insurance” will always have this problem, which is why it should be used rarely and only for unforeseen events.
John, if a doctor is misrepresenting a patient’s condition or the procedures he performed so he could collect more money it’s fraud. I’ll guarantee they would stop if they saw one of their friends in a perp walk.
artk, you think dodctors trying to help their patients get medical care should be in a perp walk? how heartless.
Well Vicki, I think doctors using inaccurate diagnosis codes and procedure codes to pump up their income are stealing from all of us. Do you like being mugged? If you were robbed, would you want the thief to get away with it or be punished?