Reporters at the Center for Public Integrity — an investigative journalism organization — have published a package of articles on doctors’ and hospitals’ use of aggressive medical billing practices — and electronic health record (EHR) systems — to inflate Medicare bills.
The reporters have pointed out that hospitals have used the convoluted U.S. medical billing system to “grab at least $1 billion in extra fees for emergency room visits” from Medicare, and they noted in one article that providers seem to be using EHR systems to automate the process of looking for opportunities to bill patients, and payers, for more expensive services.
“Regulators may lack the auditing tools to verify the legitimacy of millions of medical bills spit out by computerized records programs, which can create exquisitely detailed patient files with just a few mouse clicks,” the reporters write.
Medicare and Medicaid fraud investigators seem to put out more press releases than private plan investigators do, but, clearly, this is a problem for private plans as well as government plans.
Ddoctors and hospitals clearly try to overbill patients with private coverage as well as patients in Medicare. About a year ago, my own doctors found ways to turn my own “free” checkup into a $400 sick visit, and, in the process, gave me a file that made me look as if I were probably ineligible for life insurance, disability insurance or long-term care insurance because I was already dead.
Concerns about provider upcoding will come as no surprise to anyone who can remember reading any newspapers back in the 1970s.
Doctors today may have justifiable complaints about health insurers devouring their time with efforts to micro manage bills and demanding absurd provider discounts.
My own health plan often seems to deduct about 80 percent or 90 percent of a provider’s list price before paying a bill. Of course those kinds of 80 percent and 90 percent discounts are going to lead doctors and hospitals to look for passive aggressive ways to sneak in extra charges.
But the insurers began harassing the providers in the first place because the providers teamed up to strangle any organizations whatsoever that tried to find ways to rein in the providers’ fees. The early federal antitrust actions involving health insurance usually centered on doctors’ moves to kill managed care organizations.
Insurers have supported efforts to modernize and streamline medical billing and overall medical practice administration by having the federal government subsidize a shift to EHR systems.
If providers use EHR systems the way crackers — hackers’ evil cousins — use “port scanning” software to speed up the search for weaknesses in victims’ defenses — then it seems as if a shift to EHR systems might not be such a great thing for the U.S. health finance system.
Provisions in the Patient Protection and Affordable Care Act (PPACA) could help, by “bundling” more payments to providers and encouraging groups of providers to join together to manage the cost of patient care and suffer the consequences when costs get out of hand. The changes could end efforts to use EHR systems to maximize upcoding by sharply reducing the use of detailed billing codes in billing.
But those payment reimbursement pilots and “accountable care organization” pilots could backfire, from a patient’s perspective, if the providers decide to manage costs by skimping on patient care rather than increasing their own efficiency.
The end result could be that the brokers and benefits consultants who somehow survive the PPACA commission cuts could be the only ones standing between the patients and providers and plans that try to cut costs the bad way.