"One Cannot Measure What One Does Not Manage": The Regulators Are Not Your Friends (Part XIII-i)

From: Gilbert R (Academic PPO's Exec. Dir.)

Date: April 9, 2009 10:02:10 AM EDT

I agree it is never wise to seek out the regulators to "help" you, they are not your friend, and they will do only what is good for themselves for ink matters more to them than reality. And, I would not disagree, if the database is bogus, it should be corrected. And, yes, there are some issues with the Ingenix database used to assign UCR rates, but "the cure may be worse than the illness."

The point being made is that the people who opened the Pandora's Box, the objecting physicians, have not considered the personal consequences of their action (which is fairly typical). In 2000, the docs ran to NYS, recovery letters in hand, and demanded money for up-coded services billed to Oxford. Rather than getting Oxford spanked, they got NYS to investigate billing fraud, and the system worked against them. Not unlike the cop on the traffic patrol at the end of the month finding new opportunities to ticket, special investigation units were sic'd on them. It had a chilling effect on physician coding and cost them thousands. (It was estimated that it would cost each provider about $25,000 per year as they ended up under-coding to stay below the radar.)

The alternative was to collaborate with the plans in such matters. We did 'workouts' for the physicians, uncovering billing errors, garnering durable recoveries, and we often reached more favorable agreements in the process.

As we have said, the regulators are not your friend, ally or champion; it's in their interest to defeat you and you're personal reputation be dam**d.

The department of Insurance is feeling left out in New York State, compared to the AG, so they are issuing press releases on how they are leading the pack in beating on health plans.

I say: collaborate before confronting, but if that doesn't work, then legal and regulatory remedies are available. Medical leadership, however, has failed to position its members to do that; its physicians have effectively destroyed the local health plans that were the most responsive; left are the national plans that have less interest in collaboration.

From: Fredrick H (MD, PhD, JD)

Sent: April 9, 2009 1:10:30 PM EDT

Your approach on dealing with criminal behavior is like quietly paying ransom demands. It may work for a few people, but it encourages the illegal behavior and ultimately makes things worse for society.

If regulators are unresponsive, we need legislative action. If legislators are unresponsive, we need political action.

And, I must say, that it is not clear to me that providers (doctors and hospitals) are without guilt in this controversy. Their charges often seem far out of reason for the services offered. Just as insurers ought to openly show how they reach their "usual and reasonable" determinations, providers ought to be forced to justify their charges.

I knew an ophthalmologist who, 25 or 30 years ago, was charging around $3000 for an operation that took him 20 minutes. (The hospital charged that much again.) Two or three days a week, he'd take over the ER at a local hospital and schedule patients back to back. So he was billing maybe $40,000 a day. That's more than enough to cover any presumed "school debt"!

He wasn't a bad guy. He made so much that he'd take off 3 months a year and do it for free in Israel. But, why were American patients' insurance premiums going to pay for his preferred charity?

And there are the hospitals that routinely mark up drugs by 1000%. I don't think the question of billing fraud is so far out of line.