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Sunday, June 27, 2010

Should OBs be investigated for insurance fraud?

It's no secret: our economy (and our healthcare system, as a matter of fact) are in the crapper. Companies and insurance carriers are looking for ways to cut costs and save money. I remember back several years ago when, while driving on the turnpike, I would always see the same sign: a jail cell and something accusatory about committing insurance fraud and how it can drive up everyone's premiums.

Perhaps the finger of guilt is being pointed in the wrong direction. It's not really the consumer who is defrauding the insurance carrier; in the case of a typical hospital birth, maybe it's the physician.

The standard of care in obstetrics is to perform the same excessive battery of tests, monitors and other expensive interventions - that normally would be performed only on a high-risk patient - on every pregnant woman, often whether they need it or not. Suddenly everyone is high-risk. And I'm sure those interventions come with a hefty price tag.

And correct me if I'm wrong, but don't some OB's balk at attending Medicaid-covered patients because a government payor is less likely to pay for certain procedures than a traditional insurance carrier? Wait a minute ... maybe I do want the government running my pregnancy healthcare after all...

I switched OB's for my third pregnancy, and typically under my health plan, all prenatal visits are covered. On three separate occasions, I was billed a copay: once during my first visit (I don't remember ever having to do this with the old guy) and again when my doctor and I had a "conversation" about a VBAC - which basically consisted of her lecturing me in a nice way and feeding me inaccurate information. I considered this part of my pregnancy care and planning, together, the birth of my child; she considered it a consultation.

The third time, they noticed some swelling in my lower extremities and that my blood pressure was elevated. Nothing new from my last pregnancy (and I wasn't billed for it then, either), and apparently not that uncommon in the rest of the pregnant population. But no - this was considered "outside of the scope of prenatal care" and I was again billed. (But apparently that brief hospitalization for observation was considered part of regular prenatal care, because I never saw a bill for that one. I mean, isn't everyone admitted briefly for observation during their pregnancy??)

After awhile I was beginning to wonder if my doctor was nickel and diming me to death just to eke out as much money from me as he could in addition to what the insurance company was paying out. I realized later that, because they were so overbooked, she had charged me a copay because I had questions. And actually wanted answers. Which was much more than I got from the other guy (Me: "I wondered about why I never had the urge to push during my last labor." Him: "Oh, don't worry about that. We'll help you with that when the time comes."). If he talked any more to me, he'd have to charge me for it. Because, when you're herding a dozen or more pregnant women through the door every day, time is money, you know!

I can't imagine if I had been completely new to pregnancy and birth, with no information whatsoever, trusting my doctors implicitly and feeling like I had no need to question them. They basically have no time to tell you anything of consequence except weigh you, collect your pee, measure your belly and dismiss you.

Fast forward to the birth: again, no time to wait on things like slow labors, broken waters with no sign of labor in sight (one site, albeit an article published in 1999, suggested inducing if labor hadn't started within four hours), or first time mothers who are slow to dilate. You get the idea. The clock is ticking! As a result, the inevitable unnecessary induction is scheduled, often leading to the ubiquitous unnecesarean.

Enter insurance fraud.

Personally, I think doctors with high rates of induction and c-section should be investigated. Unless you're a high-risk doctor (and really, everyone is now, no doubt, because isn't pregnancy a risk?) there is no reason why doctors like the one mentioned on the Birth Sense blog (Aka "Jack the Ripper," God help us!) should get away with such abuse of their power and the tools to carry it out. Do you ever wonder if someone who is processing the claims these doctors submit thinks, "Wow, Dr. So and So induced nearly a dozen patients in X amount of time," or "Dr. So and So sure does a lot of c-sections."

We know that a c-section costs more to do than a traditional vaginal birth, as it should. But consider this: when you tally up the cost of anesthesia, the supplies, this that and the other that are all part of a claim, it is expensive. Multiply that by the number of women having c-sections these days (around 32 percent), and you have a booming "industry."

And since a vaginal birth tends to be cheaper, there are easy ways to quickly run up the tally: IV fluids. Induction of Pitocin, several doses. Epidural or similar anesthesia, several doses. Introduce complications such as shoulder dystocia or fetal distress, use of monitoring (which is pretty much done to everyone, regardless), drugs to revive or resuscitate the baby, etc. and that's more money that's ultimately tacked on to the bill. Some of it's warranted - saving your baby after a uterine rupture during a, let's say, non-induced VBAC, for instance. (i.e. something that inherently could not be helped and was not caused by either a medical error or unnecessary intervention)

Not to mention that in the case of a complicated vaginal delivery or c-section, you will probably require more monitoring from nursing staff, as will your baby, and usually a longer hospital stay. Perhaps even minor surgery to repair damage caused by such a traumatic, rushed birth. Multiply that "cascade of interventions" by the number of women who are induced - sometimes for real reasons, sometimes not - in this country, and again, you have a booming business. CaChing!

Not long ago The Unnecesarean posted about billing costs in pregnancy and delivery. Many readers who commented through the FaceBook link remarked how their c-section births were upwards of $45,000. (Yes, that's thousand.) Still others said they or their insurance companies were getting billed for procedures that never happened in their births:
After my DD was born, I received the actual itemized list of charges that the hospital submitted to my insurance company. I was at the hospital about two hours before she was born and left 23 hours later. The only intervention I had was a heplock. I was charged for pitocin I did not receive and I was charged for anesthesia I did not receive. I called my insurance company about this, and they just shrugged it off.
If this isn't insurance fraud, I don't know what is. And even more alarming is that her insurance company couldn't have cared less that she was attempting to save them several thousand dollars.

If more OBs were penalized for excessive interventions and surgeries that weren't warranted, perhaps it could open some eyes in this country about the abuses going on in maternal care. (Unfortunately, I realize the lines are blurred in what's considered truly 'necessary' and what isn't.) In a perfect world, it might help, in some way, to lower the c-section rate because now the people responsible for paying the bill are starting to pick up on how much over-billing is occurring. (I'm convinced that if it were any other division of medicine, this investigation probably would have already happened by now.) They've already been talking of 'de-incentivizing' certain maternity costs that mean the OB would get paid the same, regardless. While this might stop some abuse, I'm not sure how well it's working, and do think that surgery should cost more because of the level of skill involved. But it certainly shouldn't be used to the point that it is.


The Deranged Housewife said...

There are some things definitely worth mentioning that I didn't go into here - it's like a giant hamster wheel of Cause and Effect. Like how:

- doctors charge more to insured patients to cover the costs of the under- or uninsured
- People sue because they didn't get their "perfect baby" even though studies have shown that less care is often better. We fail to realize, also, that neonatal death rates have not improved even though we have more access to technology and medicine than we did decades ago. Take EFM, for instance. An imperfect science that has been criticized by some and yet still used routinely, it often leads to many unnecesareans because it fails to even detect a baby who truly does have cerebral palsy. The improved technology no doubt exists, or you could just go back to using your instincts and pure medical judgment to make important decisions (which, yes, I know, are still fallible). Relying on a machine to do your work for you isn't doing much better, though. Perhaps they don't *want" that technology to improve, though, because it automatically pads a paycheck? (Conspiracy Theory thought for the day LOL)

- Even fellow doctors are critical, though, of the less is more approach. If you have a baby in the NICU because of meconium aspiration, such as the case of an infant in question under Dr. Biter's care, you are perceived as not having done enough by critics like Dr. Amy. However, this can typically happen in a situation where the doctor did too much, and yet goes virtually unnoticed in the medical community. She rants against Dr. Biter and his numerous "lawsuits," and yet that doesn't mean a whole lot, on paper: in the litigious society we live in today, we have to look at who's suing and why. Example: the mom who experienced catastrophic U/R during a VBAC attempt, when her physician, by the patient's account, let the baby go without oxygen for 12 minutes. As a result, the *insurance company,* not the doctor, was sued; because they didn't warn the patient about the risks of a VBAC.

Just another spoke in the Hamster Wheel of Cause and Effect.

AtYourCervix said...

There is a lot of nickel and diming going on in the hospital. We just changed from a global charge system on L&D to literally where we are charging for every little thing (well, almost every little thing!). It's actually ridiculous. Now, instead of checking off 'vaginal delivery, epidural, pitocin augmentation" for a normal vaginal birth with pitocin augmentation, we have to keep a tally of each IV fluid we run, the number of hours run, each IV push, each IV piggyback med - and charge for EACH hour/medication for "nursing services" related to the administration. I can see how L&D is trying to get more reimbursement for what we have always done as nurses - but to nickel and dime every little thing?? L&D/OB is the lowest reimbursement area as far as insurance goes - so I can understand the why of trying to get more reimbursement. But what about better bargaining with the insurance companies about how much they pay/reimburse for global charges? Doing these "charge for every little thing" on our charge sheets takes up much more nursing time - how about charging for that excessive time? Charging to document? Because seriously - less than half of my shift is actual nursing care. The majority of my time is documentation or other BS.

The Deranged Housewife said...

So do they even have a space for "natural vaginal delivery, no Pitocin, no epidural"? :)

One Catch 22 is that the very same insurance companies are also forcing physicians to see as many patients as possible in one chunk of time, which is unrealistic and leads to gaps in care, I'm sure. The patient walks away totally uninformed and still doesn't know what just happened. Do you think Obs have, overall, less time than the average physician to spend with their patients?

Anonymous said...

I had a VBAC on 6-11. Only meds were two doses of penicillin-G for GBS and 1 bag of pit postpartum. We AROM'd to induce labor due to gestational hypertension. No other interventions or meds. The majority of supplies on the delivery table were left untouched/unopened.
My OB bills the same fee regardless of mode of birth. C-section is same as vaginal and he doesn't charge extra for VBAC (my former provider charged an extra $200 for VBAC)
The hospital billed my insurance company $6267. Ins paid $1642 (negotiated rate) and our portion was $800. My OB billed $2650 and received $1656 from insurance and our portion was $414.

AtYourCervix said...

Yes, we have separate charges for each individual item.

-Vaginal delivery
-Induction/augmentation with IV medication
-Induction/augmentation with PO/vaginal medication
-Cesarean section
-Cesarean section with bilateral tubal ligation
-Neonatal intervention, level 1
-Neonatal intervention, level 2
-Intrauterine resuscitation, level 1
-Intrauterine resuscitation, level 2

- use of breast pump (daily charge)
- Amnioscentesis
- Outpatient, <4 hrs
- Outpatient, each additional hour
- Outpatient extended (up to 23 hrs)

And so on, and so on......

AtYourCervix said...

What bothers me (several things really!):
-the wasting of nursing time, trying to add more and more to the charge sheets that we have calculate at the end of every shift
-the overuse/abuse of the EMS system, and with people on medicaid who don't give a darn about making "clinic" visits to L&D every few days (at a minimum charge of $1000 to walk in the door)
-how uninsured/self pay patients pay the FULL hospital charges, while insurance companies can negotiate how much they'll pay/reimburse (which is woefully much less than what is charged!)

I could go on. But I'll shut up now.

sara said...

I delivered within 20 minutes of arriving at the hospital but was somehow still charged for "labor" and 2800$ for a delivery room. The bill also showed a charge for medication I did not receive. I was able to get the labor charge removed, but the 2800$ for the delivery room I was only in for about an hour remained. It's a little ridiculous that the charge is the same no matter how long the room is used. I mean, seriously?!

The Deranged Housewife said...

I will have to see if I can find the bills the insurance sent me for my last two births. I never saw a thing from the first one.

AYC, does the fact that insurance companies negotiate for pricing mean that OBs are charging exorbitant fees for their services, knowing they'll get what it's really worth rather than what they're asking? Not sure how else to put this. In my time at a hospital I never dealt with billing.

I can see what you mean about it taking away from nursing time ... maybe there's some technology that can be used to cut the paper work ... but unfortunately I think you're one of a breed of nurses that actually wants more time with each patient! I think we've all had nurses that act like we're nothing more than an inconvenience and want to run back to the nurse's station to discuss Lord of the Rings ... GAH.

Amy W. said...

My second son was born 10 minutes after arriving on the L&D floor and our insurance was still billed over $4000 for "birthing". Whatever that means. Literally all they did was suction him when he came out. Of course having insurance, our portion to pay was much less than that but I still found it outrageous for them to charge that much when they didn't even *do* anything or use any equipment, etc. I never thought to bring it up with anyone (to reduce the charge) because I figured that was just the base cost for a vaginal birth and it couldn't be changed. But in this case it was the hospital cost and not from my OB.

When I went over my birth plan with my OB a few weeks before this he joked that my entire birth plan was probably obsolete since I'd most likely deliver in the elevator on the way up. I wonder if that would be free? ;)

When I was in the hospital for my pre-term contractions I was given a stool softener every day (I guess just because that is what they do?) but once I realized how much they were charging for that one tiny capsule I said I didn't need it anymore. I didn't even know I needed in the first place, they just brought it to me each day and never really acted like it was optional. I don't know why I never asked about it in the first place and just blindly took it (Hello! Duh!).

With my first we were charged for the glucose water the lactation consultant poured all over my breast when trying to force my barely 9 hour old baby to nurse when all he wanted to do was sleep- and boy was he letting her have it! She never asked me if I was okay with that, but of course we were billed for her decision.

I have no problem with paying someone a reasonable amount for helping me with the birth of my baby/stay in the hospital/newborn care, etc. but things have certainly gotten out of hand! Love your thoughts :)

The Deranged Housewife said...

When I worked in the pharmacy, we would routinely stock the Pyxis machine (the computerized drug cabinet that nurses accessed for medications) with stool softener, Milk of Mag, Tylenol and I think a suppository. That's probably what the stool softener was. Rarely did anyone use anything other than the Tylenol.

AYC, I don't know if your hospital has something like that - Pyxis was really cool and I think they still use them. However, there were those absent-minded? nurses who still insisted on walking around with the Morphine carpuject taped to their ID tag ... which created a fun discrepancy for me to later account for. Not. :P

AtYourCervix said...

Yes, we have pyxis machines for dispensing medications. It can be such a pain in the butt though - fax the order to pharmacy, nurse enters height/weight/allergies into the computer system so the pharmacy can enter the orders, wait an hour for that to actually happen - THEN we can pull out the med(s).

It is such a long, tedious process!

Oh, and that doesn't even cover the OTHER computer system to document med administration!

The Deranged Housewife said...

I guess we always did that when the patient was admitted. We had a computer printout thingy running all the time that would print out patient's admission stuff (probably can't do that anymore because of HIPAA) and so we'd have some idea of who was in L&D, for instance. We always had I think at least 5 epi syringes/bags made in advance and replenished when we got low. I do remember once we were running low on Pitocin and had to pull some from night cabinet in case we ran out - I remember thinking, "So what?" LOL If only I knew then what I know now ...

Anonymous said...

"... After my DD was born, I received the actual itemized list of charges that the hospital submitted to my insurance company. I was at the hospital about two hours before she was born and left 23 hours later. The only intervention I had was a heplock. I was charged for pitocin I did not receive and I was charged for anesthesia I did not receive. I called my insurance company about this, and they just shrugged it off.

If this isn't insurance fraud, I don't know what is. And even more alarming is that her insurance company couldn't have cared less that she was attempting to save them several thousand dollars."

this is one of the reasons WE don't have insurance. We pay for our own medical bills in cash. We call and talk to the people in charge of negotiating rates and get a lower rate. Usually what the insurance companies pay without having to pay the insurance company anything or having to go through a third party to make decisions that pertains to us only.

I also think that insurance takes away the patient's responsibility and accountability for his own health. i think we need to educate ourselves better regarding health issues. The doctor should be used as a counselor not decision maker in your health life. Why would I want another party involved to tell me what to do?

My last hospital delivery (hate them. I rather birth at home. This last time was not possible due to my own ignorance. Another story, another comment.) they charged us over $6,ooo and we paid $2400. We had no medications, or interventions...that was the price for a normal vaginal delivery. thinking of it now, i should have negotiated a better rate because I left the hospital one day early, when the norm is to stay 48 hours. I had to sign a waiver to leave I should have got a better discount for not using the extra day! Duh! :(

Oh, well... hopefully I won't need to go to the hospital the next time, God willing.

anyway, great post. :)

The Deranged Housewife said...

Years ago, I read an article about this - how women were bartering and negotiating for maternity services and paying out of pocket. It actually takes quite an educated consumer to do this, I think, which it sounds like you definitely are. Obviously as we are seeing with the healthcare problem in this country, many people use it as a safety net and ignore the fact that they should be taking better care of themselves. Good point.