Physician Manipulation of Reimbursement Rules for Patients

Wynia, Matthew K.; Cummins, Deborah; VanGeest, Jonathan B.; Wilson, Ira B.

doi:10.1001/jama.283.14.1858

Cited by 210 publications

(108 citation statements)

References 18 publications

Supporting

Mentioning

104

Contrasting

Unclassified

Order By: Relevance

“…In outline they find that appeals to professional judgement by referring doctors can be successful in over-riding scientific, protocol-based decision making. In contrast to the strategies of deliberate`gaming' described by some commentators (Morreim 1991, Freeman et al 1999, Wynia et al 2000, these doctors engage in a more subtle form of cultural resistance.…”

Section: Power Relations In Rationingmentioning

confidence: 93%

Introduction: A sociological perspective on rationing: power, rhetoric and situated practices

Light¹,

Hughes

2001

Sociology Health & Illness

View full text Add to dashboard Cite

The analytic power of sociology stems from examining closely the deep structures and power relations that underlie the rhetorics and practices of individuals, groups and organisations, by assuming a radical disengagement from them. Such is the analytic promise of sociological research into rationing, where unexamined rhetoric prevails and detailed empirical studies are thin on the ground. Intellectuals and policy makers, as well as those who pay the bills ± be they governmental bodies, employers, insurers, or individuals ± need the unclouded gaze of the sociological eye more than ever, as the rhetorics of rationing swirl around them. For rationing has become a predominant issue in the economic, moral and political discourses on health care. Yet as Conrad and Brown (1993:3) observed,`rationing has received little sociological attention'.The sociological perspective has much to offer. At a time when scholarly thinking about rationing is dominated by the discipline of economics, sociology can help us to understand how economic transactions are embedded in social relations (Granovetter, 1985), which place limits on calculative rationality. Rationing provides a valuable array of social practices for exploring power relations in health care systems, particularly the linkage between resource allocation, rhetoric and the interests of different parties. Sociological studies can also complement and extend philosophical and ethical work on rationing by providing empirical case material grounded in the practical circumstances of real-world decision making, and investigating whether the ethical issues recognised by actors in the health care system correspond with those described in the scholarly literature. Our aim as editors was to put together a volume that would start to address some of these issues, and we think that a decade from now one will find that an important body of research has been achieved.

show abstract

Section: Power Relations In Rationingmentioning

confidence: 93%

Introduction: A sociological perspective on rationing: power, rhetoric and situated practices

Light¹,

Hughes

2001

Sociology Health & Illness

View full text Add to dashboard Cite

show abstract

“…[1][2][3] In response to multiple pressures, physicians have reported changes in practice administration, billing, and coding of clinical diagnoses. 4,5 Some examples include documenting suicidal behavior, although the patient did not report this, to obtain an urgent psychiatric assessment; deliberate misdiagnosis of depression and substitution with another code; and overstating severity of symptoms to obtain managed care coverage for cardiac surgery. 5,6 Miscoding, gaming, and substitution with alternate diagnostic codes are methods that some physicians use to obtain patient services or additional reimbursement, or to attempt to minimize stigma of a diagnosis.…”

mentioning

confidence: 99%

Coding of Pediatric Behavioral and Mental Disorders

2002

View full text Add to dashboard Cite

ABSTRACT. Background. In response to changing reimbursement and other pressures in the health care environment, many physicians have reported the use of alternate coding to substitute for certain clinical diagnoses. However, very little information is available on how physicians who care for children approach diagnosis and coding dilemmas for behavioral and mental disorders, which often present unique additional challenges.Objective. Our study sought to describe the frequency of alternate coding, different approaches to coding, and attitudes toward diagnosis and coding practices by physician specialty.Methods. We conducted a mail survey of 1492 physicians-497 developmental/behavioral pediatricians (DBP), 500 pediatricians (PED), and 495 child and adolescent psychiatrists (PSY). The main outcomes were survey items on frequency of alternate coding (never, rarely, monthly, weekly, daily), use of different coding strategies (use of somatic symptoms, modifiers, and substitution with other terms), and attitudes on coding practices (Likert scales of agreement). We analyzed outcomes by physician specialty and demographics using Pearson's 2 and multivariate logistic regression.Results. Overall response rate was 62% (787 of 1269 eligible physicians). The majority of physicians had used an alternate code (DBP 83%, PED 68%, PSY 58%), and many respondents reported monthly-daily alternate coding (DBP 60%, PED 36%, PSY 27%). Physicians used multiple approaches to diagnosis and a variety of coding options, which varied by physician specialty. Financial issues were commonly cited reasons for alternate coding-both to obtain patient services and to receive physician reimbursement. However, challenges of diagnostic classification and coding subthreshold symptoms were cited as frequently as reimbursement issues. Stigmatization, confidentiality, and parental acceptance were mentioned, but reported less frequently. Very few practices and providers have organized administrative methods of alternate coding (26%) or receive feedback on denied claims (46%). Most physicians believe that alternate coding is justified in the present system; however, some physicians expressed concerns that these practices may contribute to stigmatization or lead to improper management decisions.Conclusions. Alternate coding is commonly reported; however, approaches to diagnostic coding vary by provider specialty. Reimbursement issues are important, but other challenges in diagnosis and classification hold special relevance to children with behavioral and mental disorders. There seems to be a great need to reconsider the separate goals and uses of clinical diagnosis and administrative coding. Additional study is needed to assess how reported coding practices may affect administrative data, patient care, and health care economics. Pediatrics 2002;110(1). URL: http://www.pediatrics.org/ cgi/content/full/110/1/e8; diagnosis, medical practice management, reimbursement, medical records, insurance claim reporting, mental health services.

show abstract

“…).… I agree to allow Schering, or its authorized agent(s) to review the medical, financial and insurance records for this patient at any time for the purpose of verifying the patient' s eligibility status for the Program…" While Hippocrates may have instilled in physicians the notion of "First, do no harm," the US legal system' s impact on physician' s considerations to avoid the appearance of fraud and unethical behavior is large. 3,4 The last statement included above provides permission for inspection, with possible subsequent criminal and civil litigation against a physician should eligibility be lost in the interim between the initial application and re-order. Therefore, it is incumbent on the physician to assure that the financial qualifiers for the patient when he or she initially applied to the program have not changed.…”

Section: The Authors Respondmentioning

confidence: 99%

The Authors Respond:

Zonca¹

2007

JMCP

View full text Add to dashboard Cite

Physician Manipulation of Reimbursement Rules for Patients

Cited by 210 publications

References 18 publications

Introduction: A sociological perspective on rationing: power, rhetoric and situated practices

Introduction: A sociological perspective on rationing: power, rhetoric and situated practices

Coding of Pediatric Behavioral and Mental Disorders

The Authors Respond:

Contact Info

Product

Resources

About