Conversely, managed care organizations are often blamed for hindering and delaying payment for legitimate services in order to improve their bottom lines. In response to the overbilling, insurers would automatically "downcode" some expensive, complex claims to lesser ones and even reject claims. The process of downcoding was done through the use of computer programs that did not have enough information about the content of clinical encounters, and so even properly coded claims were affected. In September 2004, a federal appeals court upheld a class-action lawsuit on behalf of doctors charging that insurance companies had schemed to curb reimbursement for services.1
ETHICAL CONSIDERATIONS
What, then, are the ethical obligations of health care providers? Because auditors look to the medical record to validate billing, providers are expected to document thoroughly and completely on every case.5 The general rule is for the provider to examine and document a little more than needed so that the coders can maximize coding and determine the appropriate level.2,10 Keep in mind that it is not illegal to document too much, as medical decision making (MDM)—the term used to describe care complexity, not documentation—drives the level of care. Documentation only supports the MDM. Because upcoding is illegal, an in-depth, highly documented chart should not be coded higher than the case's complexity. However, documenting something not in fact included in the examination is fraud.11 Experience will help, as demonstrated by the Kapa study, which found that accuracy improved as physicians matured professionally and learned about appropriate billing.3
Health care providers have to be on guard against unfair auditing as well. The Office of the Inspector General (OIG) began an audit in the mid-1990s that targeted physicians who used residents in their medical care. Critics of this audit process (called PATH for Physicians at Teaching Hospitals) pointed out that the OIG refused to take into account the amount of underbilling that occurred when they determined how much an institution owed the government. They also noted that the assessment of penalties implied deliberate wrongdoing as opposed to inadvertent error. Cohen and Dickler stated, "Public officials charged with verifying the accountability of physicians should, for their part, make sure that the process is fair."12
This dilemma impacts the general public as well. Both the Horner and Kikano studies revealed that problems associated with our current coding and billing extend beyond practitioners to include multifaceted systems and the need to interpret complex rules.6,7 Tactics that boost profitability often worsen efficiency and drive up the costs of health care, potentially creating problems of truthfulness and justice. Instead of providers acting on the principle of beneficence, they could end up causing long-term financial harm to the public through raised medical costs. Another risk is that investor-owned, for-profit care brings about a new value system that dissolves community roots and Samaritan traditions of hospitals, converting health care providers into instruments of for-profit care and viewing patients as commodities.8
CONCLUSIONS
What will come about from the various litigations and settlements? Changes will become apparent in the coming years. Insurers will be forced to turn to other means of effecting cost savings, such as raising deductibles, lowering fee schedules, and taking steps to improve accuracy in billing.1 PAs and other health care providers can play a key role in advocating for a system that truly cares for those who are most in need, views documentation and billing in a patient-centered context, and looks for ways to enhance care as well as ways to control the costs associated with it. JAAPA
Helene Hill practices in emergency medicine in Jackson, Michigan. Matthew Hill (her husband) is an assistant professor of philosophy at Spring Arbor University and is finishing his PhD in ethics at Durham University in Durham, England. The authors have indicated no relationships to disclose relating to the content of this article.
F.J. Gianola, PA, and Jim Anderson, PA-C, ATC, department editors
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