Physician Manipulation of Reimbursement Rules for Patients
Between a Rock and a Hard Place
Matthew Wynia, Deborah Cummins, Jonathan Van Geest, Ira Wilson
American Medical Association
Synopsis and Summary
A study was done to determine at what rate physicians manipulate the rules of reimbursement in order for patients to receive services for which they may not otherwise be granted under utilization review rules though the physician may find the service necessary. The 1998 study was a random study that contained a national sample of 1124 physicians who were surveyed through mailings and the response rate was 64%. Three areas of concentration were involved that asked if the physician’s (1) exaggerated the severity …show more content…
From these data, we cannot tell whether this is because they did not have to or because they chose other avenues to obtain the care, or whether their patients did not receive needed care. The last scenario would be particularly worrisome for patients and their physicians, in part because current case law suggests that physicians are legally accountable for providing needed care and that they do not derive legal immunity by agreeing to accept health plan coverage rules. That is, compliance with health plan rules does not provide protection against malpractice litigation and losses stemming from failure to provide an acceptable standard or care. Of course, failure to adhere to health plan coverage rules and manipulating these rules, even to benefit patients, also has potential legal repercussions.” My own conclusion is that this is a very scary situation in that if physicians are exaggerating the severity of patients conditions, reporting false signs and symptoms, and changing diagnoses when billing patients this could actually harm the patient in the future say if they are seen by other health care professionals who do not know their true health condition and they are then mistreated due to false signs and …show more content…
Due to this as well as time constraints physicians are gaming the system to give their patients the care that they need regardless of how they have to go about it, they are going as far as outright lying about the patients conditions in order to get needed care without having to jump through the utilization reviews hoops. Patients need to be better health care consumers and physicians need to have sufficient time with patients as well as to be honest and go through the legal steps that they have to in order to practice ethically. In my professional career I will certainly bill properly and question anything that I see as suspicious. If the physician that I am working for performs illegal acts I will either quit the job or report them or
Between a Rock and a Hard Place
Matthew Wynia, Deborah Cummins, Jonathan Van Geest, Ira Wilson
American Medical Association
Synopsis and Summary
A study was done to determine at what rate physicians manipulate the rules of reimbursement in order for patients to receive services for which they may not otherwise be granted under utilization review rules though the physician may find the service necessary. The 1998 study was a random study that contained a national sample of 1124 physicians who were surveyed through mailings and the response rate was 64%. Three areas of concentration were involved that asked if the physician’s (1) exaggerated the severity …show more content…
From these data, we cannot tell whether this is because they did not have to or because they chose other avenues to obtain the care, or whether their patients did not receive needed care. The last scenario would be particularly worrisome for patients and their physicians, in part because current case law suggests that physicians are legally accountable for providing needed care and that they do not derive legal immunity by agreeing to accept health plan coverage rules. That is, compliance with health plan rules does not provide protection against malpractice litigation and losses stemming from failure to provide an acceptable standard or care. Of course, failure to adhere to health plan coverage rules and manipulating these rules, even to benefit patients, also has potential legal repercussions.” My own conclusion is that this is a very scary situation in that if physicians are exaggerating the severity of patients conditions, reporting false signs and symptoms, and changing diagnoses when billing patients this could actually harm the patient in the future say if they are seen by other health care professionals who do not know their true health condition and they are then mistreated due to false signs and …show more content…
Due to this as well as time constraints physicians are gaming the system to give their patients the care that they need regardless of how they have to go about it, they are going as far as outright lying about the patients conditions in order to get needed care without having to jump through the utilization reviews hoops. Patients need to be better health care consumers and physicians need to have sufficient time with patients as well as to be honest and go through the legal steps that they have to in order to practice ethically. In my professional career I will certainly bill properly and question anything that I see as suspicious. If the physician that I am working for performs illegal acts I will either quit the job or report them or