Interesting article on Obama’s take on “health care fraud”. http://www.npr.org/templates/story/story.php?storyId=124544394&ft=1&f=1027&utm_source=twitterfeed&utm_medium=twitter
Personally, I find the title misleading – I believe it should be insurance fraud. The healthcare is being provided and, more than likely, appropriately provided. The general public, I have found, is unaware of what happens with their insurance and the doctor’s office once they have their visit, procedure, or “other” done. Many times I have found myself explaining to friends and family what actually happens. After working in pharmacy for roughly 15 years and another 2 in a physician practice plus my years of healthcare IT, I am pretty familiar with most of the aspects of claims on insurance.
Now here is the secret – your doctor “bills” your insurance company with numeric codes based on a standardized coding system. This system is based on what the doctor saw you for, what he did in the appointment, any tests performed, and any supplies used (that’s an overview statement). Then the insurance company looks at the bill, sees if all the “i”s are dotted and the “t”s crossed and sends them payment based on a pay scale or fee scale or based on their own modification to the “bill”. The modification can include a request for more information or justification for the billing. At this point the doctor may take what the insurance company sends, responds to the insurance company or appeals the payment/decision. This can take upwards of 90 days to achieve a payment to the doctor. In the meantime, you signed a financial responsibility form when you first went to the doctor. So after a set period of time if they cannot get the insurance company to pay or cannot get them to pay the full “billable” amount then YOU receive a bill in the mail.
Now usually Medicare & Medicaid are targeted first because those are the ones the federal and state governments have control over. Then the other insurance companies can come after them as they are considered the financial “benchmarks” for most of the fee and billing schedules. Disclaimer: all this is a very high-level scenario and is subject to negotiation by your employer, insurance company, and insurer.
So once again, we are lumping another small part of health care into the larger picture discussion of the health care reform. Does anyone know what our number 1 priority is with health care reform? Is there a top 10 list that David Letterman has outlined for us? If yes, please send me the link because, though I detest politics, I really want to know what to focus on when I blog and how it affects what I am interested in – healthcare IT, public health, and individual health and access.