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It’s time to correct abuses by health care providers

CalMatters
CalMatters
 2021-09-22

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In summary

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

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By Tom Epstein, Special to CalMatters

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

My mother loved a pillow on a chair in her den that read “Screw the Golden Years.” She cited it frequently to lament the health challenges of aging.

As I’ve grown older and accumulated the aches and pains of a body wearing out, I’ve seen the wisdom of her pillow. Now approaching my 70 th birthday, my need for medical care has increased dramatically.

As one well versed in the health care system and blessed with good insurance coverage, I expected to receive quality care in a supportive setting. Instead, my family has consistently encountered medical practices with brusque 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 confronted a life-changing condition, the physician treated me as if I were the MRI film and not a person. He asked no questions and after five minutes walked out of the room while I was still seeking treatment options.

To add insult to injury, I later received a bill for an additional payment beyond what my Medicare Advantage plan covered, a practice called balance-billing. As someone familiar with health care law, I knew that was not permitted. After I complained, they reversed the charge, claiming it was a software mistake in their system.

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

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

I had a similarly unsatisfying experience visiting a different medical specialist for an unrelated malady. Again, the specialist couldn’t wait to get out of the room. He asked very few questions and left in five minutes.

On another occasion, a close family member visited a local neurologist who concluded she had a degenerative disease that would impact her life forever. Rather than demonstrating the empathy such a diagnosis required, he estimated she might have 10 good years left and suggested that she create an advanced directive for end-of-life care. He then gave her a four-page handout and sent her on her way.

Needless to say, she never returned to that doctor.

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

I knew that was unnecessary but waited a few minutes for the physician to emerge. For about 45 seconds, she asked me the same questions that were on the handout I received when I entered. Then she left.

The medical group later billed my Medicare PPO plan $260 for a physician visit.  The federal government explicitly prohibits doctors from charging patients if a COVID test is the sole medical service provided. It’s likely this provider is filing fraudulent claims for many of their COVID test patients.

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

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

It’s time to radically reform the incentives in our health care system that motivate physicians to maximize their earnings 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, “first, do no harm” needs to cast a little more sunshine onto the golden years.

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