The other day, I got a "courtesy" email from an insurance company asking for my explanation of why I had a higher number of level 4 office codes than my peers.  (Office codes vary from level 1 to level 5 in terms of complexity and cost, although recently level 1 codes are gone.)  I couldn't believe it.  I have, if anything, undercharged patients throughout my career.  So I had the office manager run our codes for the office, and we are all fluctuating within the same levels of coding (there are four doctors in our private practice).  I wrote back to the insurance company explaining this and stating justifications for my codes in a brief summary. 

But as I got to thinking, I wondered why insurance would look at this one aspect of my specialty practice and not others.  Why not look at procedure overutilization, especially highly reimbursable procedures?  I know of a few procedures that some doctors do more in a week than I do all year.  Part of this is my non-aggressive approach to surgery, but part is pure greed in physicians to make extra money, at the expense of patients, and insurance, through high reimbursement procedures.

Three times this summer, I saw patients for second opinions after they were seen and worked up at the cost of roughly $10,000.  They were subsequently scheduled for an office-based procedure, which would have billed out close to $30,000.  All three came from the same practice across town.  During my second opinion, I explained the anatomy and pathology of their problem, and then I had them try a $12 over-the-counter medicine, and if that worked, consider an $800 procedure.  All patients did follow through with the cheap procedure, forgoing their first opinion, and so far have had excellent results.  Why wouldn't insurance delve into how many MRIs or knee scopes an orthopedist is doing and look more aggressively into the ones with increased percentages of such procedures?  In this way, they could flesh out who is abusing the system.  For that abuse does happen on a grand scale.

The problem with abusing the system for money is that it has become the reactionary response to the HMO approach of the late 1980s and '90s (neither of which I am favorable to).  Now hospitals and doctors are on the same page.  In my previously mentioned example, by taking a patient through a stepwise approach to a non-emergency problem, I am doing the simplest and least costly thing required to fix the problem.  I could order more tests than required, leading to more surgery than required, and my punishment would be...a higher salary, higher reimbursement for the hospital, and better accommodations and attention from the drug/equipment representatives as well as the hospital.  If I took the more logical route and tried to save money for the patient, and therefore the insurance company, the equipment and drug representatives hate me, the hospital calls me an underutilizer, and I still get random audits from the insurance company who benefits from my approach.  The only person who is happy is the patient, which is why we are in medicine, to help the patient, but this system is a big problem.

What the solution is, I am not sure.  I fear that nothing will work because it would involve relying on integrity and honesty among all players.  All have, to some degree, been tainted by the almighty dollar.  I know from personal experience that the hospital systems and pharmaceutical companies are opportunistic.  They are unlikely to change. 

I suspect that if an insurance company put effort into seeing which doctors overutilize testing and procedures, they could audit those doctors, but would there be any follow-up punishment?  I doubt it.  If there were, such as suspension of license or termination, perhaps we could scare some physicians into increased integrity.  But again, I doubt that will be done.  What can the insurance companies do against the pharmaceutical companies and hospitals?  I suspect even less.  But they have billions of dollars to spend thinking of alternatives.

Until then, when seeing a doctor, remember that you are the ultimate decider of your health care options.  Ask for options, and if you think you are being taken advantage of, find a trusted source and get a second opinion.

Image: P.J.L Laurens.