It’s Time to Correct Health Care Provider Abuse


In summary

Physicians and medical groups maximize their income by limiting the time spent with patients and adopting abusive billing practices.

By Tom Epstein, Special for CalMatters

Tom Epstein was a senior executive with a nonprofit health plan and served as assistant commissioner of the California Department of Insurance.

My mom loved a pillow on a chair in her den that said “Screw on the golden years”. She frequently cited him to deplore the health problems associated with aging.

As I got older and accumulated the aches and pains of an exhausting body, I saw the wisdom of its pillow. Now approaching my 70se birthday, my need for medical care has increased dramatically.

As a connoisseur of the health system and with good insurance coverage, I expected to receive quality care in a favorable environment. Instead, my family has always encountered doctor’s offices with blunt specialists and deceptive billing.

A few months ago I experienced severe sciatica pain for the first time, so I visited an orthopedic group in Walnut Creek. As I faced a life changing condition, the doctor treated me like I was the MRI movie and not a person. He didn’t ask any questions and after five minutes walked out of the room while I was still looking for treatment options.

To add insult to injury, I subsequently received an invoice for an additional payment beyond what my Medicare Advantage plan covered, a practice called balance billing. As someone familiar with healthcare law, I knew this was not allowed. After I complained, they waived the charge, claiming it was a software error in their system.

Nonetheless, the medical group billed me for my next two visits as well, only reversing them after I objected. Federal law clearly states that participating physicians cannot charge patients more than Medicare allows. California recently passed a law prohibiting this practice in other circumstances as well.

I wonder how many Medicare beneficiaries the group has billed that blindly paid the illegitimate fees. Regulators should take note.

I had an equally unsatisfactory experience visiting another medical specialist for an unrelated disease. Once again, the specialist was anxious to get out of the room. He asked very few questions and was gone in five minutes.

On another occasion, a close family member visited a local neurologist who concluded that she was suffering from a degenerative disease that would impact her life forever. Rather than show the empathy that such a diagnosis required, he estimated that she had maybe 10 good years left and suggested that she create an advanced guideline for end-of-life care. He then handed her a four-page document and sent her back.

Needless to say, she never returned to this doctor.

In another disturbing medical encounter, I recently had a COVID-19 test at an outpatient clinic in East Bay. After a technician administered the swab, he asked me to wait for a doctor.

I knew it was unnecessary, but I waited a few minutes for the doctor to come out. For about 45 seconds, she asked me the same questions that were on the document I received when I entered. Then she left.

The medical group then billed my Medicare PPO plan $ 260 for a visit to the doctor. The federal government explicitly prohibits doctors from billing patients if a COVID test is the only medical service provided. This provider is likely to file fraudulent claims for many of its COVID-tested patients.

This practice, called upcoding, is common among providers who seek higher reimbursements for the services they provide. Payers try to prevent the practice, but it’s complicated to prove and difficult to enforce.

My mother, a smoker, died of cancer at the age of 70. She never had the opportunity to fully experience how the golden years can be for people with lingering health issues.

It’s time to radically reform our healthcare system’s incentives that motivate physicians to maximize their income by limiting their time with each patient and adopting abusive billing practices. Medical schools, specialist societies and physicians themselves should make correcting these abuses a priority. If they don’t, policymakers and regulators must aggressively exercise their authority.

A profession guided in part by the maxim “do no harm first” must shed a little more sun on the golden years.

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