HMOs’ Shell Game to Avoid Paying Doctors Hurts the Patients

When a patient arrives complaining of severe chest pains or a mother brings in her child coughing up blood, doctors can’t wait for clarification on whether this test or that procedure is covered by the managed-care industry.

But in trying to do our job--providing the right care in a timely fashion--doctors and hospitals are getting ripped off so badly by health maintenance organizations that we find ourselves increasingly unable to meet our costs.

Medicare reimbursement is a serious problem as well, but there the difficulty is more the complexity and sluggishness of a government bureaucracy as opposed to the nimble variations on a shell game that is employed by HMOs to delay or deny reimbursement claims filed by doctors and hospitals for treatment they’ve provided their patients.

Sometimes HMOs use so-called claim-denial quotas to pressure reviewers into rejecting claims.

Sometimes they simply change the reimbursement rules without notifying doctors, so that tests or treatments that were covered one day aren’t covered the next.

And sometimes they sit on payments to benefit from the money held.

In general, these big HMOs leverage the fact that they are, indeed, big businesses.

They know that most doctors will give in to the “hassle factor” rather than go to the trouble and expense of trying to obtain proper reimbursement from the HMO bureaucracy.

This pervasive nickel-and-diming of doctors and hospitals adds up: HMOs process more than 100 million claims a year, amounting to tens of billions of dollars.

In private practice, doctors struggle to keep open their doors when they can’t count on being paid for the work they perform.

In California alone, more than half of all physician groups are on the verge of insolvency.

Patients are hurt when HMOs use cost rather than medical necessity in deciding to approve or deny coverage.

By systematically siphoning off funds needed to pay for treatment, these practices are undermining the foundations of our health-care delivery system.

It is upsetting when our electrocardiogram laboratory at one of California’s largest hospitals or my colleague’s pediatric division lose hundreds of thousands of dollars because of unpaid claims. We need that money to maintain a high quality of medical care for our patients, but much of it must be diverted to hire accountants to track down unpaid claims.

So what happens?

The biggest component in hospital expenses is nursing salaries. Consequently, hospitals are forced to cut back on nursing budgets.

When you have fewer nurses, you have to close beds. When you have fewer beds, patients pile up in emergency rooms.

And when the emergency room gets clogged beyond capacity, it must, by law, be placed on “divert,” meaning it must turn away ambulances.

This, in turn, pressures doctors to send patients home early to free up beds.

And patients released too early often experience complications and end up calling an ambulance again.

In frustration, doctors and several state medical associations have turned to the courts for relief. The result is a landmark case being pressed against some of the nation’s largest for-profit HMOs. The managed-care industry suffered a major setback last week when the Miami federal judge overseeing the case certified the doctors’ suit as a class action.

If you and I don’t pay our insurance bills, in full and on time, we’re cut off.

It’s time that HMOs are required to meet the same standards as the rest of us.