Doctors struggle with health plansCan small practices survive more Medicaid patients? By Jill Coley (Contact)
The Post and Courier
Sunday, May 11, 2008
The Post and Courier Dr. Helen Bertrand This year might make or break James Island pediatrician Dr. Helen Bertrand. A steady increase in Medicaid patients during the past decade could push her out of business. Medicaid reimburses doctors less than the cost of care, driving many physicians to limit the number of Medicaid patients they accept. In the past decade, the number of children covered by Medicaid has increased dramatically, Bertrand said. Exact numbers were not available from S.C. Department of Health and Human Services. "Coverage does not mean access," Bertrand said. "If it's not adequate coverage, you can't get the kids seen." And the ranks of Medicaid beneficiaries are expected to grow. Under the proposed South Carolina cigarette tax plan, the threshold for children would shift from 200 percent of the federal poverty level to 250 percent. Children who fall between 150 percent and 250 percent of the federal poverty level would receive State Children's Health Insurance Program, or SCHIP. The children's insurance program expanded earlier this year, moving the band of coverage to 150 percent to 200 percent, from the previous 133 percent to 150 percent. That increase made coverage available to another 80,000 children, said Jeff Stensland, director of public information for the state's Medicaid agency. Unlike traditional fee-for-service Medicaid, SCHIP is a managed care plan called Healthy Connections Kids and is based on the state's health plan. To complicate matters further, in March, managed care plans became available for traditional fee-for-service Medicaid patients. Medicaid patients must choose between two or three plans, depending on where they live, or one will be chosen for them. They can opt to remain in fee-for-service, but they must actively choose to do so. "Now the phone calls are beginning," Bertrand said, as she and her staff must help patients navigate the new plans, which might or might not include her practice. One hanging point is medication to control behavior, she said. Paperwork is required for approval, and some plans are cutting dosages. "It's out of our control," she said. The system is confusing for patients, too. Natalie Backman brought her 2-month-old son, Tyler, to monitor his milk allergy. Tyler also was due for his two-month check-up, but Bertrand had to check what kind of Medicaid managed care plan he had before she could combine the visits. Slightly less than half of Bertrand's patients have Medicaid. She has three full-time employees and has heard some say the day of the single practitioner is over. Her salary for 2007 was less than half what she made 20 years ago. Participating in medical research studies has helped her stay afloat, she said. Rich Lindrooth, director of Medical University of South Carolina's Center for Health Economic and Policy Studies, said private practices must ration Medicaid levels to meet overhead costs. Doctors need a mix, he said, although hospital practices can cover more Medicaid patients. Also, larger pediatric practices with several doctors might be better able to absorb a larger Medicaid patient load and overhead cost. Compounding the problem of low reimbursement is the greater need for health care in the Medicaid population. "If Medicaid patients required the same work as regular patients, the system would work," Bertrand said. "They need a lot of guidance. Pediatricians are in a position to have a huge impact on poverty if we are paid well and fairly enough to provide real medical homes that influence health care behaviors and choices." |
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Comments
This article has 34 comment(s)
Posted by Thomas1776 on May 11, 2008 at 2:51 a.m. (Suggest removal)
Doctors will lie in there attempts to fleece taxpayers. Make them prove it. How many filed false claims for treatment and never get caught? Tons of them. Tons!
MUSC is the worst.
Posted by Neponset on May 11, 2008 at 5:52 a.m. (Suggest removal)
There are a few bad apples in every barrel, but the vast majority of doctors are ethical and competant men and woman.
Running a prectice is an expensive operation and when the return does not cover costs - its time to close as so many med. facilities have done, especially in less populated ares.
Posted by Neponset on May 11, 2008 at 6:09 a.m. (Suggest removal)
Sorry about misspelled words, since I had to compose quickly, as I keep getting timed out after a short time ie. about one minute
Posted by ForPnC on May 11, 2008 at 8:46 a.m. (Suggest removal)
Neponset - Off topic here. Try typing your messages in notepad then copy and paste into this message box. Works for me every time!
For this article - Doesn't everyone realize that this country has plenty of money for our health care? We have so much that we keep sending it overseas to take care of those people first.
Our health care system SUCKS.
Posted by RTC on May 11, 2008 at 8:53 a.m. (Suggest removal)
I remember when both doctors and hospitals could refuse to accept Medicaid patients.
If a hospital is private, or a doctor is in private practice, they should not be forced to accept these patients, as they drive up the cost of medical care for all of us.
Posted by LutherVanderhorst on May 11, 2008 at 11:35 a.m. (Suggest removal)
Dr. Bertrand, how much did you make last year?
Posted by 3olivesmike on May 11, 2008 at 11:36 a.m. (Suggest removal)
Hey Thomas. Re: Doctors and false claims. Let's see your data. If you have the proof file a "qui tam"(that's a whistleblower) suit with the Federal Government, make some money and go on vacation. Put up or shut up.
Posted by Neponset on May 11, 2008 at 12:19 p.m. (Suggest removal)
This business of attacking doctors bothers me. Granted some doctors will get a lot of equipment and use it on every patient and charge big bucks. But I am concerned that we are attacking the people who provide the help we need. The problem today is that there are too many folks who eather can't pay or chose not to pay and the rest of us are forced to pay their bills. Perhaps we need a nation health program to force those who can pay to pay. Doctors have always taken the indigent.
Posted by Neponset on May 11, 2008 at 12:44 p.m. (Suggest removal)
correction. Last sentence should read: In the past doctors would take care of the indigent ie. before they were overwhelmed by this demand for gratis service.
Posted by abitskeptical on May 11, 2008 at 12:54 p.m. (Suggest removal)
Dr. Bertrand probably made less than a plumbing contractor last year.
She is a dedicated physician who spends quality time with her patients. I don't mind waiting, though I usually don't wait long, because when she sees my child she never rushes us out.
She is very sensitive to the needs of her patients, including the financial situation of their parents.
She is an incredible resource for our precious children. She spends a large amount of time, in addition to patient care, keeping up with all advances in pediatrics--one of the faster changing fields of medicine.
She is a down-to-earth but extremely intelligent, informed, highly professional & hard working person.
The fact that she makes 1/2 of what she did 20 years ago...means, in reality, that she makes even less, if inflation is factored in.
I'd wager a bet (if it wasn't illegal) that her staff has received more cost of living increases in salary than she has given herself.
If money was the top priority with her she would never have gone into pediatrics. She earns every dollar she makes & deserves much more than what she earns.
To those questioning what she made last year, the implied "all doctors are greedy" mantra is getting very tiring. Stop looking to the majority of them as the scapegoat for class warfare & look to CEOs of the hospitals, pharmaceutical companies, banks etc.
Posted by LutherVanderhorst on May 11, 2008 at 1:59 p.m. (Suggest removal)
"If money was the top priority with her she would never have gone into pediatrics"
Apparently, not.
Posted by abitskeptical on May 11, 2008 at 2:36 p.m. (Suggest removal)
So glad you've seen the light.
Posted by KidYendor on May 11, 2008 at 2:49 p.m. (Suggest removal)
This is simply more burden put on the private sector by the government's welfare state. State legislators will be responsible for more of it with the cigarette tax. Notice the comment that slightly less than half of the doctor's patients are on Medicaid. Unfortunately, there is no shame in being a member of the welfare state as shown by the picture and name of one of the doctor's welfare state patients and mother publicly posted for all to see.
Posted by Thomas1776 on May 11, 2008 at 6:34 p.m. (Suggest removal)
3olivesmike,
I am pleased you love me.
God Bless You :-)
Posted by Thomas1776 on May 11, 2008 at 6:48 p.m. (Suggest removal)
Nearly one of four Americans say it’s ok to defraud insurers, says a survey by the consulting firm Accenture Ltd. Some 8 percent say it’s “quite acceptable” to bilk insurers, while 16 percent say it’s “somewhat acceptable.” About one in 10 people agree it’s ok to submit claims for items that aren’t lost or damaged, or for personal injuries that didn’t occur. Two of five people are “not very likely” or “not likely at all” to report someone who ripped of an insurer.
Nearly one of 10 Americans would commit insurance fraud if they knew they could get away with it. Nearly three of 10 Americans (29 percent) wouldn't report insurance scams committed by someone they know.
More than one of three Americans say it's ok to exaggerate insurance claims to make up for the deductible.
One of three Americans says it's ok for employees to stay off work and receive workers compensation benefits because they feel pain, even though their doctor says it's ok to return to work.
Seven of 10 Americans say workers comp fraud is a widespread problem, and 45 percent say fraud is increasing.
Posted by Thomas1776 on May 11, 2008 at 6:51 p.m. (Suggest removal)
Nearly one of three physicians say it's necessary to game the health care system to provide high quality medical care ~~~ Journal of the American Medical Association.
One of 10 physicians has reported medical signs or symptoms a patient didn't have in order to help the patient secure coverage for needed treatment or services in the last year ~~~ Journal of the American Medical Association.
More than one of every three bodily-injury claims from car crashes involve fraud ~~~ Insurance Research Council.
Criminal convictions increased 31 percent ~~~ Coalition Against Insurance Fraud.
************ How many doctors in the Charleston Tri County area are committing fraud?
Posted by RTC on May 11, 2008 at 7:38 p.m. (Suggest removal)
My cousin works at the MUSC Eye Institute, and she told me it is common practice for employees in the billing dept. to alter the codes in order to get coverage for a patient.
This is totally wrong. Can you imagine if all doctors in private practice did this?
Posted by ChasCarolinaGirl on May 11, 2008 at 7:53 p.m. (Suggest removal)
Thomas1776: You are off the rocker with any comment you leave. I have never understood where you come from w/ the comments you say. You make no sense.
It is VERY expensive to run a physician's office. You would apparently have no clue. I know for a fact that in the specialty that I work in, Medicaid may pay $10 per visit. That is for a specialist, not a family physician. It is ridiculous and not fair.
As for Drs not accepting Medicaid patients ... Just imagine something happening to your family or you losing your job and you might have to use Medicaid for a little while until you get back on your feet. How about if you or your child becomes sick and you need to see someone? You would not have to be limited to what Dr you could see.
I do agree that there are corrupt people out there, but going to school for that long and having that much knowledge is a huge waste to commit fraud. Im sorry, that is my 2 cents.
Posted by Neponset on May 11, 2008 at 8:12 p.m. (Suggest removal)
The reality is the phrase "cost shifting" ie. get the folks who can pay - pay thru the the nose at hospitals.
Posted by abitskeptical on May 11, 2008 at 8:54 p.m. (Suggest removal)
Thomas, where did the numbers in the 6:48 post come from?
Fraud of any kind is bad.
I'd like to see the numbers on fraud within the insurance industry...fraud from the hands of the insurance industry against the insured, fraud at the hands of the insurance industry against medical practices to whom they owed payment on behalf of a patient.
I wonder if the Insurance Research Council & the Coalition Against Insurance Fraud have any such studies they'd like to share?
Posted by abitskeptical on May 11, 2008 at 8:59 p.m. (Suggest removal)
Oh, I see where you got the numbers.
Posted by gamecockdoc on May 11, 2008 at 11:17 p.m. (Suggest removal)
Re RTC post: no, private practice doctors do not have to sign up to take medicaid patients. It is elective. I take medicaid patients and yes, when you factor in the staff time to workout the details for the patient vs your reimbursement...you do lose money. Running a practice is EXTREMELY expensive. We double book medicaid patients because 8 times out of 10 they no show. When they both no show that is time taken away from an otherwise "paying" patient so we lose money. Healthcare is a BUSINESS! So many people look at it as an obligation doctors are to provide but at the end of the day, it is a business like any other type of business...you need to make money to keep the business open.
Posted by gamecockdoc on May 11, 2008 at 11:27 p.m. (Suggest removal)
Re Thomas and the billing fraud.....yes, there are offices out there that do commit fraud. But guess what smart guy, when the insurance company (including medicare or medicaid) audits the office, you get caught so this does limit the number of brave offices out there willing to bill for procedures not performed. Yes, audits do occur and doctors do get pinched but you don't read about that much in the news, only malpractice issues because that sells newspapers.
About the "altering codes in the Eye institute for billing purposes"...The chief complaint (what brought the patient in) drives the exam and the codes that are coded so either the doctor is committing fraud by changing the codes or your cousin is changing the codes the doctor coded during the exam. Either way, it is unethical and eventually, they will be caught but in the end it is the doctors fault if an employee did that without their knowledge. So, in this day and age, you see how doctors are getting the short end of the stick all over.
Posted by abitskeptical on May 12, 2008 at 7:29 a.m. (Suggest removal)
Insurance companies probably commit fraud at a rate that far exceeds any fraud committed by physicians.
I'm not excusing fraud by physicians who commit it, but I am suggesting that the main focus of your apparent disgust might more appropriately be shifted.
Insurance companies commit fraud in a way that makes it difficult to directly attack.
They regularly deny claims that they know are legitimate. They regularly do not acknowledge receipt of claim. They purposely delay payment.
The following is just a small sampling of all the reports & articles on this problem:
http://www.ncbr.com/article.asp?id=91838... "...Providers suspect... insurers may be purposefully slowing reimbursements to hold onto cash, and the interest it earns, longer. The delay not only hurts providers' cash flow, but also leads to soaring administrative costs."
http://www.onlinelawyerhelp.com/articles...
"Unum Group...one of the largest disability insurance underwriters in the U.S...Unum...receives countless complaints of denials of legitimate disability insurance claims..Insurance companies...practice bad faith when it fails to pay a claim without justification or if it violates the insurance coverage policy. A few of Unum's tactics to deny a claim include:
* Failure to properly investigate a claim;
* Unreasonable delay in making payments to the policy holder;
* Unreasonable termination of an insurance claim that should have been paid;
* Use biased medical exams that deem someone fit to work even against the advice of their treating physician
http://www.cnn.com/CNN/Programs/anderson...
http://www.boston.com/business/globe/art...
"Physicians are frequently shortchanged, often without their knowledge, because of less-than-transparent insurance company practice.."
http://www.statmedical.net/html/services...
"Be aware that many of these responses are simply delay tactics on the part of the insurance companies to process claims and payments."
http://www.progressnowaction.org/page/co...
http://www.gilweber.com/gw_pro07.htm
"...problems traditionally faced by physicians...One of the most troublesome...is "downcoding...a process by which payers unilaterally change submitted claims to lower-valued codes so they can pay less. Another significant issue is the timeliness of final and accurate claims settlement... collecting the proper amount in a timely manner is essential to maintaining a healthy practice, so anything a payer does to affect that is worrisome. Payment problems have surfaced up and down the East Coast..."
Posted by abitskeptical on May 12, 2008 at 7:33 a.m. (Suggest removal)
Above post directed mainly to Thomas.
Posted by Thomas1776 on May 12, 2008 at 12:42 p.m. (Suggest removal)
ChasCarolinaGirl,
Yes. We know criminals will say anything and even LIE ... even do whatever they must to AVOID detection and getting caught breaking the law.
Are you are criminal, ChasCarolinaGirl? Something tells me you might be.
Posted by Thomas1776 on May 12, 2008 at 12:47 p.m. (Suggest removal)
gamecockdoc,
They don't get caught when they list and charge for services they never did. Go ask the folks at the senior citizens centers how they and their insurance companies get ripped off.
Again. Criminals will use all sorts of methods to avoid detection and getting sent to jail.
Some people are just flat out dumb and will even lie to try to cover the plain truth. I laugh at the criminals who think they are so smart.
Posted by Thomas1776 on May 12, 2008 at 12:49 p.m. (Suggest removal)
White Collar Crime. It's real. It goes on. And even doctors engage with-in the same.
Posted by abitskeptical on May 12, 2008 at 1:11 p.m. (Suggest removal)
When did anyone suggest that doctors do not have bad apples among them?
Posted by Thomas1776 on May 12, 2008 at 4:27 p.m. (Suggest removal)
An investigation conducted by the Attorney General's Medicaid Fraud Control Unit (MFCU) has resulted in the arrests of several employees and the director of the G.B. Cooley Intermediate Care Facility for the Mentally Retarded in West Monroe, Louisiana.
Department of Health and Hospitals (DHH) officials first alerted MFCU investigators iin March to possible instances of abuse and filing of false documents by employees of the G.B. Cooley facility.
MFCU investigators conducted an investigation which turned up evidence of employees filing false documents by claiming to have worked with patients when in fact they did not or were not present at the times stated in their progress logs.
Arrested were, Margaret Brown Harris, Tonya Lashawn Harris, Marquita Karlis Pollard and Valentia Chisley Smith, all care takers in the Independent Living program at the G.B. Cooley facility. All are charged with one count each of Medicaid Fraud and one count each of Filing False Public Records.
NOTE "Alerted"
Posted by Thomas1776 on May 12, 2008 at 4:29 p.m. (Suggest removal)
The U.S. Justice Dept is suing the Medical University of South Carolina (MUSC), charging the school and its physician group with violations of the False Claims Act.
Posted by abitskeptical on May 12, 2008 at 8:29 p.m. (Suggest removal)
I believe their is more than one physician group as MUSC. Please give specifics about this case.
Posted by taz on May 13, 2008 at 9:28 a.m. (Suggest removal)
In reference to Doctor Bertrand, the area will suffer no big loss if she were to retire due to this problem, to give you some background information my daughter was a patient of this office, the office itself is dirty, with outdated filthy carpet, exam tables were found to be unsanitary with visible dirt and dust on them. Dr Bertrand has outdated medical training and often does not tell the parents what is medical fact or just medical guessing, and when it comes to transferring medical records you can forget seeing all medical records from labs and other facilities, she will not transfer them or give copy’s to parents stating the HIPPA law, which is completely wrong on her part, HIPPA gives the Parents the full rights to review and copy’s of all medical records at anytime no matter who’s office they are in. So please do not waste your time talking your child to this office, there are many other pediatricians in the low country that have nice offices that are clean, and that are up to date with the year 2008.
Posted by abitskeptical on May 13, 2008 at 5:22 p.m. (Suggest removal)
Well I saw none of the problems taz has reported.
Further not only is it complete BS to state that she has "outdated medical training" it demonstrates that he/she must not know what he/she is talking about. All physicians licensed in SC must complete 40 hours of practice related continuing medical education credits every 2 yrs.
I guess if you are more interested in how an office is decorated, you won't mind paying for all the fancy curtains & furniture. If feel sorry for you if that is how you pick out a doctor. You are bound to find out that many with the fancy offices don't deliver so fancy.