Skip to main content
No. of Recommendations: 2
Because they're paying for it, and the doctor benefits economically for doing more work. Someone has to double-check to make sure that the medical services that they propose to do for you are really necessary. Whether it's a Medicare functionary, a private insurance company, or you deciding that it's not worth incurring a large expense (an extra day in hospital) for the benefit being offered, someone has to balance the costs and benefits - and since the doctor doesn't bear any of the costs, it can't just be the doctor that makes that call.


Very naive.

How do you know (and why do you assume) goofnoff's doc is getting fee-for-service reimbursement rather than a case rate? In lots of metropolitan areas Blue Cross and other insurers are paying case rates - approx $300 whether you're in for one night or 100.

Denying the hospital payment for the last night of hospitalization is a well-honed tactic of Blue Cross. You're in for three nights, it should have been two; you're in for 20 nights, it should have been 18. They shave off a day or two of payment to the hospital and always with the reasoning is "We reviewed the records and determined the denied days were not medically necessary". Many times they give that explanation without ever having requested the records!

"Not medically necessary." Let's stipulate that that's their reasoning in goofnoff's case (because that's ALWAYS their reasoning). So the argument comes down to the attending doc's opinion vs BC's medical director's opinion. BC has the luxury of knowing that the kidney blood test indeed was stable on the day of discharge, so in predatory fashion will then argue that the last night of hospitalization wasn't necessary because the subsequent blood test wasn't worse than the previous day's test result. OTOH the attending doc is the sole individual responsible if he/she sends goofnoff home and the kidney blood test result worsens causing a readmission to the hospital.

One side is entirely levered to not being negligent and doing what's right for the patient, and the other side is levered to profitability for shareholders. It's an uneven playing field if there ever was one.

So when you say "double check to make sure...the medical services are really necessary", I think you need to re-think your premise as to who is more likely to have the patient's best interest in mind.
Print the post  

Announcements

What was Your Dumbest Investment?
Share it with us -- and learn from others' stories of flubs.
When Life Gives You Lemons
We all have had hardships and made poor decisions. The important thing is how we respond and grow. Read the story of a Fool who started from nothing, and looks to gain everything.
Contact Us
Contact Customer Service and other Fool departments here.
Work for Fools?
Winner of the Washingtonian great places to work, and Glassdoor #1 Company to Work For 2015! Have access to all of TMF's online and email products for FREE, and be paid for your contributions to TMF! Click the link and start your Fool career.