I had a conversation this morning with
a bright and articulate paralegal. She
informed me that some of her clients were
upset that we were not participating physicians
in their health plan. I explained that
there were several reasons for our non-participation
and all were to the benefit of the patient.
After reading my response she was appreciative
of our position and completely understood
the benefit to her client. In this newsletter,
I have re-printed my itemized response
so that you can be well informed as to
the reasoning and logic behind our decision
not to participate and why by having clients
treat with participating physicians you
may be jeopardizing their health and their
case.
- Managed
care plans limit both fees and visits
to such an extent as to interfere with
the patients recovery and case value.
Lack of medical specials weakens
the patients case (as do excessive specials).
The appropriate care for a patients
is what we strive to achieve. Generally
speaking, proper care is difficult if
not impossible to provide in a managed
care environment as evidenced by the
recent surge in medical malpractice
and bad faith lawsuits against participating
physicians and managed care organizations.
Recent legislation offering a Apatient
bill of rights@ is a reflection of the
nations discontent with new millennium
medicine.
- The battle
between necessary and optimal care is
still the issue. We believe our
patients deserve the best care available
to bring them back to their pre-injury
status. Insurance companies believe
that only Anecessary@ care should be
provided. The difference is a functional
outcome versus a short term pain control
outcome. Unfortunately, most managed
care physicians provide care which is
below the minimal necessary care to
assure renewal of their employment contract.
- In the context
of managed care a physician cannot serve
two masters. Either you work
for your patient or you work for the
carrier. We believe that our employer
is the patient and they deserve our
best effort. Managed care doctors are
Adis-incentivized@ from providing quality
care. The disincentives present as below
average fees, excessive pre-authorization
and reporting requirements and large
reimbursement witholds. Disincentives
also present through peer reviews and
contractual limitations regarding balance
billing.
- The doctors
who are participating doctors have contractual
obligations to the carrier/employer.
Doctors are obliged to accept reimbursement
based upon limited fees and restricted
visits. Our recent investigation has
revealed that billing only the initial
several visits on the managed care policy
and then balance billing is a breach
of the contract. Doctors who do balance
billing as contracted providers are
subject to penalties and contract termination.
From the attorney=s perspective, they
must realize that by paying outstanding
balances to participating doctors they
are not representing their clients financial
interests and may be responsible to
pursue additional reimbursement efforts
on the client=s behalf.
- We respect
our patients right to make an informed
choice regarding their provider of preference.
Patients who understand the alternatives
and consequences of managed care will
generally choose doctors who care and
demonstrate concern with their overall
health status first and their insurance
later. The willingness of a doctor to
extend the courtesy of credit until
case resolution is an expression of
compassion and concern which the informed
patient will appreciate.
- We do accept
all indemnity, Point Of Service and
Med-pay coverage towards the patient
balance. However, because we
are not obligated to accept the fee
we can balance bill in an ethical and
appropriate manner.
- Our offices
are very aware of the cost of care we
provide. We treat within self
imposed financial parameters. Our bills
and care are always reasonable and consistent
with the patient=s injuries thereby
reducing the exposure by the patient
and attorney to criticism by carriers
regarding abusive and unnecessary physician
expense.
- We intentionally
withdrew from all plans as they became
increasingly prohibitive. An
example is Managed Medicaid plans which
pay $13.80/visit after PCP referral
and prior authorization. We believe
it is in the patient's best interest,
for their health and case, to treat
with a physician group intelligent enough
to recognize the obvious conflict of
interest presented by managed care influences.
As you can see, the benefit of a managed
care reimbursement is compromised by lack
of physician loyalty, decreased quality
medical care, inappropriately low medical
specials, contractual challenges for physicians
and attorneys, and lack of patient freedom
of choice. By working with offices like
Shaw Chiropractic you have clients who
are properly treated and injuries which
are thoroughly documented thus allowing
you the ability to better represent your
client=s legal interests .
