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Tuesday, April 13, 2010

Covered vs non-covered services

In a world where the value of any given service to patients is determined by parties outside of the actual medical transaction, all sorts of strange things can happen when the gamers enter the equation. In the world of markets, we simply do not need to define what is a covered vs. uncovered service. Some parties are willing to offer goods and services. Other parties want to purchase goods or services. When the striking price is right, a transaction takes place. Everyone comes out ahead since the transaction would not happen is there were not two willing parties.

The the bizarre world of medicine where we have constructed universes of parties engaged in what can best be called parallel play, the clarity of the market disappears. While it may appear we have we defined services, some of which may be covered by insurance payments and others which are not, it is actually much more complicated. We have constructed a system of intertwined parties, tied together by ill defined contractual arrangements. Up until now it has held together because there have been domains sufficiently lucrative to entice physicians to remain part of the game, putting up with the ambiguity because there was sufficient profit  margins to be garnered.

However, this enticement to remain part in the insurance game is disappearing. Some physicians are simply leaving and moving to a cash economy. However, others have cleverly asked a simple question. What can I charge for that is not a covered service? Historically, certain domains have been universally recognized as non-covered, particularly cosmetic services. No one has questioned the ability of physicians to bill for such services independent of insurance. However, what allows physicians to bill an otherwise insured patient for these services?

The obvious answer is they are not covered but what exactly does that mean? Does it just mean that when you provide these services to patients their insurer will not pay for this? Does this mean that any service that you bill for which is not covered is by definition a non-covered service? Does that mean such services, like cosmetic services, can be charged directly to patients? This is basically the underlying rationale for the so-called concierge practices. Patients may not need such access but if they desire access, they can pay for this non-covered and non-essential service. If this is fair game, I would venture to guess that the opportunities for novel business models where any number of activities could be viewed as non-essential and non-covered services. This element of gaming has been limited until now because it was simply not worth it to push the envelope. There was plenty of money to be made by steering clear of such activities. However, times are changing.

This all might sound unprofessional, more like the scheming of money grubbing whores. However, if we remain compliant with a payment system which fails to provide remunerative recognition for legitimate professional activities which provide real value to patients, we become accessories to denying patients the very medical services they want and need. What is priced at nothing means it is not valued and ceases to be available.

 I recently read an exchange discussing internet derived health care information and whether it would render physicians irrelevant. The consensus was that physicians will always be needed to help patients understand whatever information they find. All I kept thinking as I read this was, what CPT code pays for that? In order for physicians to be paid to provide this consultative service to patients, are we required to bring them to the office and perform the useless ritual of  the physical exam (feeling a normal abdomen, looking in the ears...) before we actually get to what they really want and need. Or perhaps should we just viewreflective discussion with patients as a non covered service and charge them like we would if injected them with Botox?

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