Personal Experience with Some of the Problems in Heath Care.

[Spartacus]

Re: Personal Experience with Some of the Problems in Heath Care.

Is this a response to my post?

No commentary?

http://www.pubmedcentral.nih.gov/art...?artid=1464043

"Last-year-of-life expenses constituted 22 percent of all medical, 26 percent of Medicare, 18 percent of all non-Medicare expenditures, and 25 percent of Medicaid expenditures."

Can you imagine what will happen when the highest-number years of boomers enters their final years? And we still have 20 years of medical-industry inflation before that happens.

[Jim Nickerson]

Re: Personal Experience with Some of the Problems in Heath Care.

I began this thread to point out real experiences with one problem in health care that I encountered through my wife’s medical problem--Fraud.

Being ripped of by doctors twice regarding “just” three charges pissed me off because I perceive doctors as being the least likely members of society that have any need to resort to thievery. I’ll grant them the inalienable right to be wrong in what they may think or do about patients’ problems as long as it is because of honest stupidity, lack of up-to-date knowledge or knowledge in general, or wrong because patients can and do mislead their decision making process, but I cannot grant them license to be dishonest.

What pissed me off even more is that I believe I proved a patient has no remedy against being the victim of fraud, certainly in the State of Texas when dealing with Blue Cross Blue Shield of TX.

“Explanation of benefits” (EOB’s) are the forms I presume all insurance companies provide patients to show how the company adjudicated claims for the patients’ care.

BC/BS of TX on every EOB has a “Health Care Fraud Notice.” It reads: Health Care fraud affects us all and causes an increase in health care costs. If you suspect any person or company of defrauding or attempting to defraud Blue Cross or Blue Shield of Texas, please call us. All calls are confidential and you may report your suspicions anonymously via our toll free hotline.”

There are various types of health care fraud, but what I’ve focused on is that which occurred in a patient’s visit to the doctor, who overcharged the patient and the insurance company by up-coding an insurance claim form to a company.

Now get this, I, Joe Average, call the hotline and say what? “Hey, Hotline, I wish to remain anonymous, however, Dr. Ima Crook overcharged me the other day when I was in her office for an examination.” Hotline, “Joe, what day was that?” Joe, “If I tell you that, won’t you be able to figure out who I am?” Hotline, “Possibly, but we need something to go on, so how about giving us a date?” Joe gives up the date and hangs up hoping some way the doctor never discovers Joe reported her and that doctor doesn’t end up suing Joe for defamation or something.

To me the Hotline is a ruse. I wrote the BC/BS Fraud Unit letters detailing each incident. I wrote the President of BC/BS of TX detailing the reports to the Fraud Unit. I wrote Customer Service of BC/BS detailing the frauds of one of the doctors. In this latter instance Customer Service sent me a letter back stating that I must send the allegation to the Fraud Unit, incidentally they did not send back my 4-5-page allegation. This latter event is analogous to a bank customer walking up to a teller and saying that the man three windows over is robbing the bank, and the teller telling the bank customer he will have to notify the police.

The only thing I could document that BC/BS ever did with regard to any of three instances of fraud I alleged against two doctors was to have requested a copy of my wife’s records from one doctor. I know that because the doctor’s office sent my wife a form to sign to release her record to BC/BS. BC/BS never communicated to my wife that an investigation was or wasn’t done and certainly not that any instance of fraud was uncovered or not uncovered.

If a patient does not identify itself to the company, and despite that the company actually can effectively “investigate” an allegation of fraud, how effective might such an investigation be? If a dishonest provider is so blatant that it charges for something it didn’t do and didn’t bother to fabricate a record saying it provided a service, then the company might catch the provider. Being that generally doctors are not totally dumb, then one inclined to up-code a service probably has the presence of mind to dictate a record that were he to be investigated would serve as his/her "proof" that the service was performed.

The event my wife experienced that started this “education of Jim Nickerson regarding medical fraud” was in fact covered by a fine note by the doctor that detailed what served as his defense if in fact BC/BS ever actually critically reviewed the record—which they may have done. The doctor sent me and I reviewed his record--a record for the visit after I complained directly to him about overcharging on the day of the visit. However the note for the visit was mostly a fabrication of what actually happened during the 10-minute visit that was initially charged to us as a 30-minute visit and then submitted to BC/BS as a 20-minute visit. If I were the company and reviewed the note and accepted the note for the visit as the truth for what happened, the guy was not guilty. But in fact he did cheat and ultimately steal from BC/BS and us. Wife and I were two people who would in deposition testify what happened in 10 minutes. That there was no doctor’s record of one examination being performed at all suggests that if the Fraud Unit even reviewed the records it received, it did not look at them closely. Assuming BC/BS did find something that caused it to warn the provider he better shape up, there was never any remedy to us for the overcharges that were adjudicated to the extent of what befell us through wife’s deductible.

One conclusion I drew from pursuing fraud by a provider in claim submission to wife’s insurance company is that if one makes such an allegation one will never find out if the allegation was correct or wrong. I am rather sure that Joe Average would think he did his good deed, and he must have been wrong because he never received a subsequent EOB rectifying the overcharged visit.

I believe Blue Cross Blue Shield of Texas is the largest health insurer in Texas, and it handles the State of Texas’s employees’ insurance plan. One would expect that if an insurance company is not motivated or equipped to deal with health insurance fraud that perhaps some other State agency might have a serious interest in prosecuting fraud especially in light of the State paying the company for what is supposed to be insurance with some cost containment features. Don’t be too quick to reach any conclusions about this.

More to come: What can the Texas State Board of Medical Examiners do about physician fraud?

[spunky]

Re: Personal Experience with Some of the Problems in Heath Care.

Hmmm, the spunkster , once again points out is captialism really good for medicine, our health and mental well being :confused: Do you want the doctor worrying about the bottom line or just doing what is right for you, the patient ???? Are doctors business men or caregivers ?????? Expecting physcians to have different economic motives while living under the oppressive umbrella of captialpigism is kinda naive JIMHO :cool:

[Jim Nickerson]

Re: Personal Experience with Some of the Problems in Heath Care.

Hmmm, the spunkster , once again points out is captialism really good for medicine, our health and mental well being :confused: Do you want the doctor worrying about the bottom line or just doing what is right for you, the patient ???? Are doctors business men or caregivers ?????? Expecting physcians to have different economic motives while living under the oppressive umbrella of captialpigism is kinda naive JIMHO :cool:

Spunkster,

Capitalism: an economic system characterized by private or corporate ownership of capital goods, by investments that are determined by private decision, and by prices, production, and the distribution of goods that are determined mainly by competition in a free market.

I have never seen that capitalism plays a part in what doctors or hospitals charge with regard to the possibility that competition leads or should have led to competitve pricing, much less lower prices. I assume real competition exists in the pricing of supply items that are not patented, but that I imagine is a small part of the overall cost of healthcare.

Whatever doctors are they are not "caregivers," they are "caresellers," and I do not discount the necessity of their making a living, or the reward of even making a good living, but at some point there has to be a limit on what they make.

If doctors' main concerns are about providing care to attempt to avoid more expensive care, or to treat those who are ill so they may have a better quality of life, why, as an example, is the first question asked if one is a potentilly new patient calling for a possible appointment: Do you have insurance? 2-What company? 3-No, we don't see Medicare patients.

I went through such just in January. Wife's hand surgeon who I also saw gave me the names of 10-12 internists. I had to call eight numbers before I found one in an office where he was the new guy, and the only one who would see a Medicare patient. I interpreted this experience to say something about the interest being more in how they shall be reimbursed than it is about the possibility of wanting to see more people with problems for which their skill and knowledge might be of benefit.

There is no choice about what I wish for a provider to be worrying when it comes to making decisions affecting one's care. But all the money in the world to pay one for health care does not assure the correctness of providers' opinions and in no way assures the practice of "really good" medicine. There is little doubt in my mind that in this country one can find excellent heath care if you can afford to have more than one person reflecting upon whatever are your problems. I have no confidence were I to walk randomly into any providers' office with the expectation that in fact what I might have recommended to, prescribed to, or performed upon me is necessarily good, much less that it likely will be the best.

Unfortunately, I don't expect providers "to have different economic motives while living the oppressive umbrella of capatilism." That they don't have different motives is the problem.

[jk]

Re: Personal Experience with Some of the Problems in Heath Care.

jim,
the interposition of insurance companies between treater and patient creates its own set of incentives, and medicare, by virtue of being a federal program, has another set of its own as well. for the most common service which i deliver, for example, a brief visit during which i evaluate and perhaps change someone's medication, medicare pays 30% less than the average i am paid by private insurers. for the privilege of being paid 30% less, i am subject to federal regulations on what information must be included in the notes i write. e.g. every note must include the patient's diagnosis, even if it is the same diagnosis as the previous 50 notes. every note must document the start and finish time of the meeting, etc, etc. further, if the feds decide to audit me, as they have done to others i know, i am subject to a $10,000 fine for each violation and, theoretically, at least, jail time. i know someone who spent $130,000 on attorneys' fees during a medicare audit in which no wrongdoing was found. i've got more patients than i really want, and am not booking new appointments for new patients until may, 2 months from now, although there may be various urgent situations in which i'll fit in another new patient prior to that. tell me why i should see another medicare patient instead of some other patient who is no less deserving of treatment?

[spunky]

Re: Personal Experience with Some of the Problems in Heath Care.

JK is dead on.'


Jim, I find it odd in that definition the word "profit" is missing :confused:
I understand your position here. I agree , but the american health care system has so many conflicts built in; they are impossible to resolve.


Why, when we were children ,were prescription drug adds not allowed to be aired over television ???? What has changed since then ???

[Spartacus]

Re: Personal Experience with Some of the Problems in Heath Care.

They're still not allowed in the US or Canada, AFAICT.

Ever hear the actual name of the drug being advertised?
Any actual health claims?

JK is dead on.'
Why, when we were children ,were prescription drug adds not allowed to be aired over television ???? What has changed since then ???

[spunky]

Re: Personal Experience with Some of the Problems in Heath Care.

They're still not allowed in the US or Canada, AFAICT.

Ever hear the actual name of the drug being advertised?
Any actual health claims?

Sorry, I am cornfused:confused:

[Jim Nickerson]

Re: Personal Experience with Some of the Problems in Heath Care.

jim,
the interposition of insurance companies between treater and patient creates its own set of incentives, and medicare, by virtue of being a federal program, has another set of its own as well. for the most common service which i deliver, for example, a brief visit during which i evaluate and perhaps change someone's medication, medicare pays 30% less than the average i am paid by private insurers. for the privilege of being paid 30% less, i am subject to federal regulations on what information must be included in the notes i write. e.g. every note must include the patient's diagnosis, even if it is the same diagnosis as the previous 50 notes. every note must document the start and finish time of the meeting, etc, etc. further, if the feds decide to audit me, as they have done to others i know, i am subject to a $10,000 fine for each violation and, theoretically, at least, jail time. i know someone who spent $130,000 on attorneys' fees during a medicare audit in which no wrongdoing was found. i've got more patients than i really want, and am not booking new appointments for new patients until may, 2 months from now, although there may be various urgent situations in which i'll fit in another new patient prior to that. tell me why i should see another medicare patient instead of some other patient who is no less deserving of treatment?

jk,

A short answer is there is no reason you should change, and I probably should leave it there, but I won't

I guess everyone who goes into medicine, dentistry, podiatry, chiropractic has his/her individual reasons when they start out as a student, and I imagine why people in health care do what they do changes over time as their careers develop.

jk, what you seem to me to be doing (and I truly know nothing about the practice of any type of psychiatry) doesn't strike me as very challanging for someone who generally strikes me as quite bright--way, way much brighter than I am on things here at iTulip. I wonder if when you decided to try to be a doctor back at age 10, 15, 20, or when you decided you wanted to be a psychiatrist, did you envision yourself practicing as you are now after 30 years. Perhaps you had the insight to see out 20-30 and decided early on this is what I want with my life, and now you have it. It is possible that some or most of what you do could be just as well done by a nurse--of course trained to deal with psychiatric follow up. If you had to deliver efficiently whatever it is you deliver, could you not develop a more effecitive way than that in which you find yourself?

It would seem to me that if one practices any specialty that one would welcome exposure to challenging problems, and the wider one's doors are open the more likely one is to encounter real challenges. Perhaps this to too ideal: a notion in which a provider in more interested in treating or trying to treat things that are challenging versus those that with experience often become mundane. Why should one deal with difficult problems if one can someway deal with those that are not so difficult, this is the similar to me as saying why should I see patients with poorer insurance when I can limit myself to seeing those who pay better? I guess it all gets down to what one wants out of practice; something that is no doubt different between individuals and in the same individual over time.

Do you think Medicare just set out to be harsh with how it deals with good health care providers who may go bad or did experiences Medicare have over these years make it the way it may be today? I assume what you write about Medicare rules, fines have been in effect for some years, not just the past 5 or 10 years.

Is whatever Medicare requires in the way of documentation in psychiatric practice more than whatever "good documentation in the practice of psychiatry" should be for non-Medicare patients?

[Jim Nickerson]

Re: Personal Experience with Some of the Problems in Heath Care.

JK is dead on.'


Jim, I find it odd in that definition the word "profit" is missing :confused:
I understand your position here. I agree , but the american health care system has so many conflicts built in; they are impossible to resolve.


Why, when we were children ,were prescription drug adds not allowed to be aired over television ???? What has changed since then ???

I don't know what jk is dead on about. "Profit" is a factor that should should be removed from the equation of heatlh care in as many places as possible. If you work as a CT or MRI technician is there some profit you make from doing a top-notch job? I expect not in most circumstances. I expect too that if one really does a job inadequately that one may lose one's job. For primary health care providers these considerations don't exist, unless they are employed in some group that has serious oversight, whether one practices whatever might be top-notch care or less than adequate care, the compensation could turn out to be nearly the same, and for the one practicing at the lower end of what might be marginal care, as long as he/she isn't caught for dishonesty has nothing to fear about ever losing his/her job.

spunky, you may be totally correct that the problems with American health care may be impossible to change. What is changed with drug adverts is I guess a free speech issue, and the evolution of marketing. Marketing has become acceptable in health care and adds to the overall cost.

They're still not allowed in the US or Canada, AFAICT.
Ever hear the actual name of the drug being advertised?
Any actual health claims?

Spartacus, what are you talking about here? Drugs are certainly widely advertised on American TV, and they says the trade names and I think always show the drug name. I'll have to watch more closely, but I think drug adverts invariably insinuate they do something good for people.

[Spartacus]

Re: Personal Experience with Some of the Problems in Heath Care.

OK, maybe the law has changed - If you have heard the actual trade name of the drug something is definitely very different. When the advertising to the public first started up again (after 30 years) the companies were using a loophole - if the name is not mentioned, it's not an ad, according to the regulations that kept the advertising off the air for a long time.

note that the name of the drug is not mentioned in advertising to the general public - they tell you to "ask your doctor for the latest ..." . I've still never heard the words "viagra" or "lipitor" in a general-audience advertising.

All the companies can hope for is that the drug is well known to doctors due to specific news coverage and actual names in medical journal advertising and through free samples to doctors.

Sorry, I am cornfused:confused:

adverts invariably insinuate they do something good for people

Exactly - no specific health claims - those regulations were about specifics, and the recent advertising is about skirting those.

[jk]

Re: Personal Experience with Some of the Problems in Heath Care.

I guess everyone who goes into medicine, dentistry, podiatry, chiropractic has his/her individual reasons when they start out as a student, and I imagine why people in health care do what they do changes over time as their careers develop.

jk, what you seem to me to be doing (and I truly know nothing about the practice of any type of psychiatry) doesn't strike me as very challanging for someone who generally strikes me as quite bright--way, way much brighter than I am on things here at iTulip.

it's very challenging at times, though for varying reasons. sometimes the challenge is figuring out what's wrong with someone in the first place, in the face of scant or contradictory patterns of evidence and the absence of objective tests such as blood tests or scans. [someday we'll be using gene-chip screening and functional mri's, but we're not there yet.] sometimes the challenge is figuring out how to help someone given our current armamentarium and the particular individual's drug responses, side effect profile, personal concerns about drug effects, and concurrent medical problems. sometimes the challenge is figuring out how to convince somebody to change their behavior. of course there are other times when my work is very routine.

I wonder if when you decided to try to be a doctor back at age 10, 15, 20, or when you decided you wanted to be a psychiatrist, did you envision yourself practicing as you are now after 30 years. Perhaps you had the insight to see out 20-30 and decided early on this is what I want with my life, and now you have it.

no, i have never been good at long term planning. it feels odd to write that, as i suppose my life doesn't look consistant with that statement, but my approach has been more focussed on doing what seems interesting at the time, so i've had a number of professional enthusiasms along the way - wrote some papers on family therapy and behavioral systems/feedback loops early on, got interested in political psychology and wrote papers on the hawk-dove dialogue around arms control and one on soviet corruption, then a book on the selection and socialization of soviet leadership, did a lot of psychotherapy, got interested in managed care and spent time organizing a multisite practice and trying to organize a statewide consortium [failed], switched to psychopharmacology from psychotherapy [i got sick of hearing myself talk] and got interested in bipolar disorder - co-authored some studies and case reviews and became the local bipolar guru. meantime designed a house, had a family, got interested in investing in the late 1970's and kept up reading on that, got into various athletic activities for periods of 5-7 years per sport [squash, then tennis, then swimming, then squash]. but i never mapped out plans much in advance.
[btw, reading this, my life sounds much more exciting and successful than it feels living it.]

It is possible that some or most of what you do could be just as well done by a nurse--of course trained to deal with psychiatric follow up. If you had to deliver efficiently whatever it is you deliver, could you not develop a more effecitive way than that in which you find yourself?

we have an aprn [advanced practice registered nurse] in our practice whom i supervise, and who does what i do, but doesn't know as much as i do or have the experience i do. that's why i'm the supervisor.

It would seem to me that if one practices any specialty that one would welcome exposure to challenging problems, and the wider one's doors are open the more likely one is to encounter real challenges. Perhaps this to too ideal: a notion in which a provider in more interested in treating or trying to treat things that are challenging versus those that with experience often become mundane. Why should one deal with difficult problems if one can someway deal with those that are not so difficult, this is the similar to me as saying why should I see patients with poorer insurance when I can limit myself to seeing those who pay better? I guess it all gets down to what one wants out of practice; something that is no doubt different between individuals and in the same individual over time.

there's no lack of challenging patients of all ages. about 1/3 of my patients are teenagers. i prefer my challenges to be clinical -- i don't mind having to think hard and long, and persevere over prolonged and often frustrating treatments to help someone feel better. i prefer that my challenges not be administrative - filling out bs paperwork and saying "mother may i?" to some insurance clerk.

Do you think Medicare just set out to be harsh with how it deals with good health care providers who may go bad or did experiences Medicare have over these years make it the way it may be today? I assume what you write about Medicare rules, fines have been in effect for some years, not just the past 5 or 10 years.

Is whatever Medicare requires in the way of documentation in psychiatric practice more than whatever "good documentation in the practice of psychiatry" should be for non-Medicare patients?

i think medicare is driven by political and administrative pressures. it's like the fda - there's a "scandal" around vioxx and so the fda has to play cya and put black-box warning labels on every drug in sight for any kind of problem probable or improbable, increasing patients' worries about treatment and raising everyone's litigation risk. medicare documentation requirements are what you expect - tedious and redundant, adding a layer of beaurocratic cya lard to what should be meaningful record keeping.

[Jim Nickerson]

Re: Personal Experience with Some of the Problems in Heath Care.

if the feds decide to audit me, as they have done to others i know, i am subject to a $10,000 fine for each violation and, theoretically, at least, jail time. i know someone who spent $130,000 on attorneys' fees during a medicare audit in which no wrongdoing was found.

When wife was referred to 2nd neurologist by hand surgeon, wife went on web to see what she could find, if anything, about the neurologist. I can assure anyone who needs to be assured, that she was not looking for "dirt" or anything adverse about the guy--I think she was mainly looking to see where he was located.

Wife came upon what was more like an editorial, as I remember it, in the local medical society's journal with regard to the neurologist she was scheduled to see. It struck me that he was being portrayed in the jounal as the "posterboy" for how "badly" Medicare treated physicians. It related that this guy had been charged with 14 violations of something to do with care of Medicare patients. It pointed out that the Medicare rules were such that if he the physician wished to defend himself then he would have to go before some Medicare board on separate occasions for each of the 14 alleged violations--the board was over in Dallas. Assuming he chose to defend himself it would take at least part or all of 14 days to do so. The gist of the editorial was that the way Medicare handled these violations made it almost impossible by total impracticality to defend oneself.

I later thought why would Medicare be so difficult to deal with in such matters?

I concluded after contemplation that the way Medicare handled these violations is done to provide the health care provider a chance to "save face" with his/her family, friends, and professional colleagues. The provider can proclaim his innocence while paying the fine, saying it was totally impractical for himself to take 14 days off from helping sick folks.

DemonD mentioned insurance companies with their computer algorithms as a method he believed was used to deter fraudulent coding in the submission of insurance claims by providers. Perhaps such is what led to wife's neurologist having be accused of "Medicare Fraud."

I would bet that if Medicare accuses a provider of 13 or 14 instances of fraud or whatever anyone might euphamistically call it, that Medicare does not do such flippantly with little or questionable evidence to support its position. I would also surmise that Medicare would be unlikely to charge an individual with any wrongdoing if for some reason it did an audit and found two records that were not up to whatever Medicare says is the standard when all the other records were good records. Just a guess on my part.

Back to jk's quote above. jk, did you personally ever take off and go watch your acquaintance, I guess it was, and his attorney defend himself and actually win a case? It strikes me as more than a bit odd that Medicare would charge someone with these violations and end up losing all the cases, my presumption is that Medicare would not make just one or two charges against someone. I can't see where that much is gained by Medicare in fines or from trying to make an example out of anyone for having a couple of poor records when compared to other good records.

Just for the purpose of being skeptical, jk, is it possible that your acquaintance was guilty as charged for 13 instances I would say of fraud, not just poor record keeping per se, and paid the fine and told wife/family, friends, and professional colleagues that he was proven not guilty, but that it cost him $130,000 to defend his good name?

[spunky]

Re: Personal Experience with Some of the Problems in Heath Care.

JK is dead on about the relationship of the agency, provider and insurer. There are checks in the system, but they are damn few and far between.

I have 2 jobs. I work as an inpatient Psych ward RN, and I work as an ICU nurse. At my job where I work ICU we use a model where we have physcians that are known as "hospitalists". These physcians work for the company and are paid a salary. It doesnt matter if our census is 10% or 100% they are paid the same. No conflict there. Refering to the earlier posts in the thread; this is where I see alot of cover your ass medicine go on.

On another side note my ex wife makes a good living decoding all the billing that goes on in the medical field; it is all she does all week. When we were married we would talk " shop" and she would be on the phone at least 2x a week to the state insurance commish. She goes about 3x times a year for training, just to keep up with the billing changes for medicare. Medicare is the tail that wags the dog


This is a very complex and sticky mess we are in. I just dont see attitudes , culture and the system changing enough to have the best of both worlds.


regards

[jk]

Re: Personal Experience with Some of the Problems in Heath Care.

jim, the guy didn't pay $130,000 fine. he paid that much to his own lawyers. there was no fine. medicare dropped the matter. it just ended up costing him $130,000 to go through the process of being looked at.