The patients may end up paying out of the pockets for procedures that are not medically necessary due to incompetence of medical management. This is a true…
Everything in medical field is about knowledge, professionalism and experience. And this statement should apply not only to medical, but to administrative staff as well at any level of medical practice: would it be hospital, rehabilitation center, hospice, nursing home, physician office, treatment center, etc.
Administration, managers, support specialists, clerks and front desk secretaries, all of them, have to have knowledge of the policies, rules and regulations specific to their level of responsibilities.
Well, sometimes, one can even see total or partial opposition of the professional knowledge in action, and it’s very unfortunate. I want to share just one of many examples I had encountered.
Recently my daughter had needed an X-ray. We went to one of well known in our region chain-diagnostic centers, where I, by chance, overheard conversation between medical manager of the facility and front desk receptionist/ billing clerk. Girl who enters patient information into the system asked manager a question regarding ABN (Advanced Beneficiary Notice) form and in what instances it suppose to be filled out. Manager told her that:” ABN form has to be filled by Medicare patients when DEXA (bone density study), or chest X-ray needs to be done, because Medicare pays only 80% of the allowed fee, so they have to collect other 20%”.
I was surprised hearing this kind of answer from the manager, who, I thought, should have some kind of understanding of why we fill out certain forms.
Is it purposeful misleading or honest incompetence?
The correct answer to that question had to be:
ABN form is filled when Medicare patient receives procedure that is not covered (or may not be covered) by Medicare policies.
It has nothing to do with Medicare paying 80% of allowed $ amount. Since all MCR patients know that they are responsible for the deductible, co-insurance and co-pay, depending on supplemental coverage.
Then why MCR patients filling out ABN forms at this facility?
By regulation MCR pays for only 1 DEXA in two years. It should not be performed more then once in two years because there would not be significant changes in less time, except when patient takes certain drugs that could affect the condition. However, in case of the later Medicare would pay for the test. Which means, when patient comes to do DEXA nobody knows (or disregard the knowledge) when last time this kind of test had been done for that patient. It means, that physician who refers patient to do DEXA might don’t pay attention to the date when last time test had been performed, ordered test that is not medically necessary and patient would end up paying for it. What’s interesting that patient would not even know that test is not that necessary.
Moreover, the actual MCR payment fee is not that big, but facility might charge their established fee that could be pricy for patients. Especially, when we are talking regarding MCR patients.
So we came to unfortunate conclusion: the patient must have some knowledge about medical rules and regulations. Otherwise there is a risk to be ripped off by incompetent or simply unfair medical practice.