The Spectacular Incompetence of 3rd Party Payers

By SAURABH JHA, MD
To paraphrase Tolstoy, all competence is alike, but every incompetence is incompetence in its own way. Every time I think I’ve seen the horizon of incompetence, I’m dealt a surprise. The sun never sets on incompetence. In healthcare, incompetence can be found in odd places, such as three recent examples I encountered with third party payers.
Case 1: Downgrading Caviar to Boiled Salmon
A patient was referred for a CT angiogram run off – which is a CT scan of the arteries of the belly, pelvis, both legs and feet – a very detailed and costly study. The cardiologist suspected a pseudoaneurysm of the femoral artery. The exam was an overkill, I felt, as the femoral arteries could be covered in a CT angiogram of the abdomen and pelvis – you don’t need to image down to the toes. I was confident that a pseudoaneurysm in the femoral artery would not extend to the arteries of the feet – it would be a world record, if it did. I suggested we stop the exam in the middle of the thigh.
“That’s fraud,” warned the chief technologist, who was also an expert in billing.
“Why is it fraud to restrict the field of view to the area of clinical relevance?” I asked.
“You can’t bill for a CT angiogram run off and only do the abdomen and pelvis. That’s fraud.”
“Why don’t we bill just for CT angiogram of the abdomen and pelvis?” I asked.
“You can’t bill just for the abdomen and pelvis, the patient has been pre-authorized for a run off.”
“Yo...

Source: The Health Care Blog - July 31, 2016 Category: Consumer Health News Authors: John Irvine Tags: Uncategorized Source Type: blogs