2 topics that have captured my interest lately:
1) Medical billing and 2) PE involvement in healthcare
1a) Upcoding
1a) wnyc.org
Dr. Reinhart: Yes, people are making money in all of this( oversight and paper). The amount of money spent on healthcare in the US is now about $4.6 trillion. I believe there's a recent study in Health Affairs, a health policy journal that estimated by 2030, that amount is going to increase to $6.8 trillion per year. To give you a point of reference, this is more than double the next closest nation in terms of per capita healthcare spending. That spending isn't just being pushed in circles. People are extracting it. Money is being made through inefficiencies.
Efficiency is not a priority of our healthcare system if we look at it in the way that it's constructed. This, I think is very-- it's not just that it's a waste, it is very disheartening and demoralizing for physicians to work in this context. Because every single day, the caller before this one for example, mentioned the coding system, the billing system. In residency training programs, it's a very common thing now to have a module specifically on upcoding. How do you write your billing documents in such a way that you could bill for the maximum amount of money?
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Really? intentional upcoding is fraud. Are medical schools actually teaching it?
“Medicare fraud has been the cause of up to $60 billion in overpaid claims in 2015 alone.”
I have been upcoded for a procedure that didn’t occur and refused to pay. The charges were corrected quickly.
However, the issue is more complex. Suppose you go to an ENT for a specific ear problem. The procedure is done and the physician says “open your mouth.” you comply, the look-see takes 15 secs, and the charge to medicare was 450, reduced to a co-pay of 20.
You didn’t ask for it . Was it necessary? an example of upselling? Or an example of upcoding since, perhaps, the 450 could have been reduced to 300 if it was coded a different way? ( there are > 10,000 CPT codes) Maximizing the coding system is different from fraud.
In any case, do you want to make an issue of it for 20 ?
If medical schools are teaching how the coding system works, it’s a small step from maximizing and not underbilling, to the larger ethical chasm of upcoding for procedures that never were asked for and were unnecessary, to billing for procedures that never occurred.
1b) misbilling
I was misbilled for a Dr. visit that never occurred. Instead, it was for a physician assistant visit that did occur. Clerical error? How many times was i misbilled in reverse? Never.
1c) pre-billing - - the most annoying of the new billing practices
Billing for services that went through medicare but not secondary insurance is now a common, intentional practice. In fact, it happened at the same organization in 1b) above.
In their quest to accelerate their cash flow, they pre-bill every medicare bill online with a portal message alert. I’m sure that some people actually pay it, not realizing it’s a pre-bill. When i questioned this practice, they said that’s the way their system works. No, someone set a parameter at the software provider or the Dr’s. office to accelerate cashflow.
So, in the case of 1b) above, had i not been paying attention, i would have prematurely paid the wrong copay amount for a charge that never occurred.
Also, prebilling causes the patient to research what it’s for. Every time i go to a certain dr. , i receive an online pre-bill, multiple reminders to pay the pre-bill (which i will never do) and eventually a real bill thru the mail ( which i recommend). The confusion comes in if the amount is the same and is done on every visit, e.g. a blood test. I sometimes see 6 online pre-bills and 12 reminders to pay them. If i didn’t ignore them, i could be spending my time to understand why they are billing me. All in their quest to accelerate their cashflow.
Thus, I recommend caveat emptor for all medical bills and don’t pay medical bills until you get one through the mail and check the charges with your insurer.
2) The topic of PE involvement captured my interest as I, and people i know, have been directly affected. Everyone is, or will be, directly or indirectly affected as it continues to spread into other markets, both consumer and business, reducing choice and increasing prices along with other deleterious effects. Here’s how it’s related to healthcare:
2a) PE firms acquiring large medical practices:
freakonomics.com
Ostensibly about the vet industry, it’s really about how PE operates.
APPELBAUM: It’s not about efficiency. It’s not about economies of scale. It’s all about monopoly power.
That, again, is the economist Eileen Appelbaum.
APPELBAUM: This buy-and-build strategy is very common. It’s not like they care about pets. They don’t care about pets. What they see is a fragmented market, lots of people love their pets and are going to do everything they can to get them the best care — and they see an opportunity here. So they buy a slightly largish pet-care company. They try to find one that’s really good. And then they go out and look at who are its competitors, and they buy up the competitors. They want to monopolize. So that when you need a procedure for your pet, you have to take it to a place that they own.
APPELBAUM: Well, when you say corporate, let me just back up for a minute and tell you that the vast majority of states in the U.S. have laws against the corporate practice of medicine. And so there are real problems here. When you have a situation where healthcare is being provided by a company whose first responsibility is to maximize profit, you’re going to see profit prioritized over the treatment of the doctors or the vets and the treatment of the patients. And it is illegal in most states, but private equity at least has figured out a way around it.
DUBNER: How do they do that?
APPELBAUM: They set up a sham company that is run by a doctor. And they say to the doctors, “Your practice is owned by this.” But here’s the thing. That sham company has absolutely no assets. All of the assets of the doctors’ practices — the technology, the building, the accounts receivable, the chairs in the waiting room and so on — all of these are owned by a management-services company that is owned by private equity.
DUBNER: So does that make it quasi-legal.
APPELBAUM: No, it makes it quasi-illegal. And in fact, there is a case now out in California that is challenging private-equity ownership of doctors’ practices in hospitals. It’s being brought by the emergency-room doctors. They feel they’re being forced to not use their best judgment when they treat people. They’re under enormous pressure to stabilize the poor patients and get them out of there, whether that’s the right thing to do or not, and they are just fighting back. Let’s see what happens.
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2b) In NY’s hudson valley, westmed ( 500 physicians) was acquired by summit/walgreens and caremount( hundreds of physicians) was acquired by optum/UNH.
Summit Health has more than 2500 providers, 12000 employees, and over 340 locations in New Jersey, New York, Connecticut, Pennsylvania, and Central Oregon.
In NY and NJ,
CityMD and Summit Health Finalize Merger:
The combined organization, which has more than 1,400 providers, over 6,400 employees, and nearly 200 locations in New Jersey and New York, will offer patients a seamless experience across a full spectrum of high-quality primary, specialty, and urgent care. Warburg Pincus, a leading global private equity firm focused on growth investing, has supported CityMD since 2017 and will assume a majority interest in the combined company. Consonance Capital Partners, a healthcare-focused private equity fund, is also making an investment in the combined company. And then:
Walgreens-backed VillageMD buys Summit Health for $9B - - (thru Village Practice Management Company, LLC)
2c) 2022 UNH suit by NYS AG Letitia James:
Their latest step and allegations explained:
ag.ny.gov.
UNH completed the acquisition of Change in 2022.
With more power going to PE-owned practices and less choice for patients, premiums, medical charges, deductibles and copays will be going up for everyone. At the same time, quality of service will likely be going down.
good health to all. |
