Medical specialists overcharging – study
Medical procedures also have a specified set of numerical designations that describe the exact procedure performed. Also read Medical Billing and Coding Job Opportunities Martha R. Gore Medical coders usually work in hospitals or doctors offices; however, some may have their own business. They work in clean, well-lighted surroundings. Usually they work 40-hour weeks but some overtime may be required. In hospitals, they may work day, evening, or night shifts if the billing department operates 24 hours per day. There is little to no contact with patients. Salary and Job Outlook The salary range for a medical coder ranges from a high of $58,488 to a low of $33,777 with $43,995 being the average. The job outlook is expected to be better than average through 2016 with faster than average growth at a projected increase of 18 percent. Government regulations regarding health information and billing will ensure that there are plenty of job opportunities available. There will also be the need to replace workers leaving the work force due to retirement. Medical Coding Programs and Colleges Certified medical coders are trained in anatomy, physiology, and medical terminology. They must understand the etiology, pathology, signs, symptoms, and disease processes. Coders may receive an associates or bachelors degree at one of over 200 colleges and universities across the country. Many more institutions offer a coding certificate program.
As a result of this incentive to overcharge, medical schemes are reluctant to pay out for the benefits resulting in increasing complaints from members. The registrar of the Council for Medical Schemes, Monwabisi Gantsho, said that, last year, more complaints were received about the manner in which medical schemes and administrators pay for benefits than in any other complaint category. Of a total 5 915 complaints received by the registrarCMS, 2 411 related to benefits. Of these, 846 complaints related to instances where medical schemes incorrectly funded the benefits claims at their respective scheme rates and not in full. Unfortunately, this results in members having to foot the outstanding balance of the bill. According to the medical schemes act, your medical scheme must legally cover: Your benefit conditions in full, as per the invoice submitted by the healthcare provider. Your scheme is not allowed to use your personal medical savings account to pay for benefit conditions. The diagnosis, treatment, and care of roughly 300 serious and costly health conditions fall under benefits, including 270 diseases such as tuberculosis and cancer; and 25 chronic conditions including asthma, epilepsy and hypertension. Your scheme is entitled to nominate a designated service provider such as a doctor, pharmacy or hospital as the first-choice provider when you need treatment or care for the benefits condition. If you choose to use a nondesignated service provider and it is not an emergency situation, you may have to pay a portion of the bill. If you have a condition that is classified as a benefit, most schemes require you to register for a benefit before they will start reimbursing you as per the benefits requirements. Schemes avoid payments Gantsho notes that medical schemes are not dealing with benefits in a uniform manner and different complaints bear testament to this: Some schemes have deliberately programmed their systems to fund members benefits accounts at scheme rates and then pay the balance only after the council investigates a complaint. Other complaints related to instances where schemes underpaid claims or made no payment owing to the fact that members did not use the services of the designated service providers of the scheme, whether voluntarily or involuntarily. Some members did not qualify for benefits as their treatment did not form part of treatment protocols, but some protocols were contravening the (act) in that they were not evidence-based. This means members had been offered an incomplete package, he said.
Greedy medical specialists refuse to treat most children with serious health problems if they have public insurance
It almost sounds like the specialists are inflicting a kind of punishment on kids who have the “wrong” kind of public insurance that doesn’t pay the doctors as much in reimbursements as private insurance. Sick kids with Medicaid or CHIP had to wait over a month, about 44 days, for help. But privately-insured children with similar urgent conditions were seen in less than three weeks. For the study, research assistants compiled facts by working undercover — they posed as moms of children with seven common medical that affect large numbers of children and are serious enough to need timely specialty care: severe body rashes, obstructed breathing during sleep, Type 1 diabetes, uncontrolled asthma, severe depression, new onset seizures and a fracture that could affect bone growth. The researchers, pretending to be mothers, placed calls to a random sample of 273 clinics representing eight medical specialties in Cook County, Pennsylvania. Each of the investigators placed two calls, separated by one month, to each clinic using a script that varied only by insurance status. Only 34 percent of callers with Medicaid-insured children were told they could even get an appointment with the specialist. But if the researchers-posing-as-moms claimed they were calling about a child with Blue Cross Blue Shield PPO insurance, 89 percent were given appointments. It was obvious that how the doctor was going to get paid — whether by higher paying private insurance or by lesser paying public insurance — was of far more importance to the specialists’ offices than the severity of the child’s reported symptoms. What’s the evidence for this? In more 50 percent of calls to clinics, the caller was first asked for the child’s specific type of insurance coverage before being told whether an appointment could be scheduled with the doctor. In fact, in 52 percent of the time, the type of insurance coverage was the very first question asked. The University of Pennsylvania researchers who carried out the study noted in a press statement that previous studies have found that reimbursement amounts are the main reason doctors decide whether or not to treat patients with public insurance. But the authors of the new study think the health systems in which the doctors work may play the biggest role of all — because medical centers may have incentives that encourage doctors to avoid patients who don’t have the higher paying private insurance. This has created policies based on making the most money rather than policies based on what’s best for seriously ill kids.