Dr. Patricia Farrell on Medika Life

Is the Diagnosis Correct, or Is It a “Billable” for Charges for the Clinician’s Services?

The dilemma and stress of a healthcare diagnosis are something everyone can experience, and insurance plays a significant role.

Attorneys are held to a standard of billable hours, and, depending on how they meet this marker, it determines not only their career advancement but their remaining with the firm. These are well-known facts, but there is the question of “billables,” now that a medical appointment has been sliced down to fifteen-minute intervals (and psychotherapy is no longer one hour but 50 minutes or less), has reached heightened levels of concern. Primarily, the patient has implicit belief in their healthcare professionals, but the specter of careers, billables, and advances in healthcare cannot be ignored.

The complex relationship between medical diagnosis, treatments, and insurance reimbursement has sparked discussions on the accuracy and moral implications of medical procedures. This article examines how insurance reimbursement may affect medical diagnosis and treatments, as well as the stress it might place on both patients and healthcare professionals.

Start with one example I witnessed recently when a patient was going over their physician’s report after a visit and a medical test. The patient was shocked to see a diagnosis of neurodegeneration when the patient had never been told of that diagnosis. A brief discussion with the provider disclosed that it is often the case to indicate a diagnosis for which both the patient and the provider will receive payments. But even honest mistakes in billing can have dire results for practitioners. But what is known as “upcoding” is definitely not a mistake.

And in some hospitals, this has become the MO. But action is being taken to address this practice which may result in medical fraud by utilizing non-existent medical conditions for billing. The current action is by way of a bill, temporarily named “No Upcode.”

There’s also a problem here because not every disorder may be accurately reflected in the allowable billing codes from insurance companies or the government. Neurodegeneration may be another way of describing a medical issue that is not a major medical illness—or am I wrong here? There may be thousands of medical disorders that are NOT in the codes, so what does anyone do? Yes, you look for the closest code and use it, but it may be a frightening one or one that will affect future treatment.

How will this play out if the patient needs some type of emergency care in the future and is sent to an unknown medical facility? Reviewing the records, the medical team will not have accurate details of the patient’s prior health. Additionally, when software like EPIC contains false information, such as a medication issue that never existed and appears to be unfixable, it may be of no use. I know people who have tried for years to get their EHR errors fixed, and everyone claims helplessness on the issue, including hospital IT personnel.

On behalf of a patient, I contacted the health commissioner of my state, who assured me she would look into the issue and get back to me. That was about four months ago, at the time of this writing. I haven’t heard from her, and the patient is concerned about unknown issues that may arise if I contact this woman again.

So now we’re at a standstill after six years of trying to get the hospital in question to fix the error. BTW, medical records don’t have to be maintained after seven years at which time they can be destroyed. And medical malpractice is usually limited to two years for filing a complaint, but there are state differences and there may also be “discovery” issues involved.

Anyone wishing to contact their state’s health commissioner can do so at this link.

Not limited to medical care, I have heard clinicians indicate that, when family therapy is indicated, the therapist will note that the IP (identified patient) is the mother. She, then, is saddled with diagnoses that make her the bad apple in the basket, even though it’s the family unit that is in need. Is this ethical? It seemed that didn’t matter because reimbursement was the object and it was standard practice.

For clarification, let’s go over a few details. The basis for choosing a patient’s best course of treatment is their medical diagnosis. The connection between a diagnostic and insurance reimbursement, however, might occasionally have unforeseen results. Healthcare professionals are forced to balance their attention between the clinical features of a patient’s condition and making sure the diagnosis meets the requirements for insurance coverage. This may occasionally cause the emphasis to shift from strictly clinical issues to making sure the diagnosis is “billable.” If this sounds a bit troublesome to you, we’re in the same boat.

Insurance reimbursement, therefore, has an impact on healthcare professionals’ treatment decisions. Treatments that are more likely to be reimbursed in some circumstances are given preference, sometimes overshadowing those that could be better suited or more effective for the patient’s condition. As a result, it is possible for financial concerns to unintentionally take precedence over patient care, creating concerns about the morality of medical decision-making.

Patients may experience a great deal of stress as a result of insurance reimbursement and medical care. Not knowing whether an insurance company will pay OR deny a claim for a particular diagnosis or course of treatment can cause anxiety and worry. Many patients struggle with issues like “Can I afford the recommended treatment?” and “What if my insurance doesn’t cover it?” This uncertainty may discourage patients from seeking early medical attention or pursuing necessary therapies, which could eventually be harmful to their long-term health. Harmful seems to be putting it mildly because patients may forestall treatment and die because they believe reimbursement will be (or has been) refused. How much is a life worth?

Patients without comprehensive insurance may feel more stressed because they are aware of the close connection between their financial situation and their healthcare decisions. How many healthcare facilities depend on reimbursement for care, and how do they convey this to their staff? How often have you heard that a hospital is recruiting someone because they have a very large caseload and, therefore, ensure more-than-adequate funding for that person and their staff? How much charity care is provided?

When dealing with chronic or serious medical illnesses that call for regular treatments and interventions, this stress may be very acute. Patients may also feel pressured to make health decisions that are in line with what their insurance will pay for, perhaps compromising the best possible care in the process.

Patients may have significant administrative burdens while navigating insurance policies, coverage restrictions, and claim denials. Claims denials, too, are a hot topic since we know that some companies are using AI for denying claims. It reminds me of a physician who was making decisions on Social Security Disability benefits. Most clinicians take at least one-half hour per claim, but this man claimed he did 600 in an hour and was making an extraordinary amount of money doing it. Who was checking on the denials he was, most probably, making automatic denials?

Having trouble comprehending insurance terminology and being concerned about unforeseen out-of-pocket costs can cause frustration and bewilderment. As a result, patients may spend significant time and effort attempting to understand insurance-related issues, which would otherwise be focused on their own health.

Medical diagnoses, treatment choices, and insurance reimbursement are intricately linked, with significant ramifications for patient care and healthcare delivery. Recognizing insurance reimbursement’s possible effects on patient well-being and healthcare professional stress is critical because it helps keep the healthcare business alive.

Stakeholders can work toward a more harmonious strategy that emphasizes accurate diagnoses, efficient treatments, and overall patient health by acknowledging the ethical problems presented by this connection and promoting patient-centered care.

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Pat Farrell PhD
Pat Farrell PhDhttps://medium.com/@drpatfarrell
I'm a licensed psychologist in NJ/FL and have been in the field for over 30 years serving in most areas of mental health, psychiatry research, consulting, teaching (post-grad), private practice, consultant to WebMD and writing self-help books. Currently, I am concentrating on writing articles and books.


Medika Editor: Mental Health

I'm a licensed psychologist in NJ/FL and have been in the field for over 30 years serving in most areas of mental health, psychiatry research, consulting, teaching (post-grad), private practice, consultant to WebMD and writing self-help books. Currently, I am concentrating on writing articles and books.

Patricia also acts in an editorial capacity for Medika's mental health articles, providing invaluable input on a wide range of mental health issues.

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