Yesterday’s post about testing work comp patients for opioids struck several nerves; perhaps the most sensitive involves frustration on the part of payers unhappy about paying for tests prescribed by docs who don’t read the results.
That and the outrageous prices charged – and paid – in some states by some labs/physicians.
In addition to several public commenters, I heard from two medical directors yesterday about docs who order tests and never take action when the results are “inconsistent” with expectations. Over the last few weeks I’ve have had similar conversations with pharmacy directors at two large state funds. Simply put, these folks are happy to promote best practices, but do NOT want to pay for tests that are never read.
What’s a payer to do?
First, watch the coding and reimbursement very carefully; your medical bill review function may be able to help identify inappropriate coding and/or coding that looks to be primarily reimbursement-driven.
Second, direct away from those providers engaged in unacceptable billing practices. Yes, I understand you cannot force claimants to use or not use specific providers in some states. I also know payers can encourage/recommend/channel/suggest/educate claimants about specific providers; Express Scripts had some solid results by educating patients about physician dispensing, and their lessons learned can inform your approach.
Third, make the high billers’ lives difficult by doing everything possible to reduce reimbursement; require medical necessity statements, require evidence that the test was actually done, reduce reimbursement by whatever legal means necessary. I’ve talked to a couple payers who have successfully battled physician dispensers using this tactic; one roundtabled the issue with adjusters who came up with several very creative and effective ways to make life extremely difficult for companies billing for physician-dispensed drugs.
And the adjusters really enjoyed it…
For docs who don’t read the tests they have ordered, an outreach program wherein a test with aberrant findings triggers a case manager contact with the treating physician is in place at several payers. While this – like everything else in workers’ comp – is no panacea, it does alert the treating doc that there’s a problem.
There is also technology available and currently in use that can determine if a document emailed to a recipient is opened.
Worst case, the payer can use this information if the claim goes to litigation, and/or to seek a change in physician, and/or to demonstrate culpability on the part of the physician if the patient has an adverse event.
What does this mean for you?
Drug tests are a tool; used correctly they can be very helpful. But tests that are bought and never used are a waste of money. And using the wrong test is like trying to tighten a bolt with a hammer.
POC testing in the physician’s office is usually worthless. A small fee by the physician for reviewing the test results and ACTING on them is reasonable.
In regards to outrageous prices charged. Please note: Confirmation Urine Testing Fees are not set by the Testing Lab or the prescribing Physician. Fees are set by the Insurance Providers (Medicare, Medicaid, Workers Compensation and Private Insurance).
Though it may be true that some Physicians do order tests that may be unnecessary, however, in 9 States that have passed the Pain Management Clinic Act, it is the LAW that patients that are prescribed narcotics for Chronic Pain, must be urine drug tested as a minimum twice per year. It is the law in Florida, Texas, Georgia, Kentucky, Louisiana, Mississippi, Ohio, Tennessee, and West Virginia.
Yes it is unfortunate that some prescribing Physicians may not read the lab test report, this is a waste, however, I do assure you that most of the reports are read by Physicians who care about their patients.
Note: Physicians do not and can not (by Law) profit from the Urine Confirmation tests that they send out to Confirmation Testing Labs.
R Brown – thanks for the comment. I’d suggest that your information re fee setting in the workers’ compensation world, while perhaps factually correct (legally states could or do have the right to set fees but many do not exercise that right) is practically incorrect. In states without fee schedules for drug testing, fees are determined in large part by the billing entity.
If you could provide a citation for your statement “most of the reports are read by Physicians” that would be most appreciated.
As to your statement “Note: Physicians do not and can not (by Law) profit from the Urine Confirmation tests that they send out to Confirmation Testing Labs.”, this is a distinction without a difference. The explosive growth of physician owned labs is a clear indication that docs are reaping huge financial benefits from testing over and above what they can make from qualitative tests.
Joe,
The problem with your suggested methods for non payment is that good providers are lumped in as well. We have seen this over and over again with other ancillaries, whereas, insurance companies develop rejection methods for outliers and apply to the entire industry. This makes collecting even more tedious and what will eventually cause “some” good providers to leave the system. Btw, the good providers leaving are probably the best providers the system has.
JS
John – thanks for the comment. In my experience, payers and their billing entities can selectively address types of treatment (e.g. physician dispensing) via business rules programmed into their payment systems.
Payers can also identify specific providers or treatment codes or diagnoses or locations of service or combinations of multiple metrics and develop reimbursement specific to that metric/metrics; this is being done today to speed payment for preferred physicians by several payers. While some payers may well adopt a blunt instrument approach, their competitors will benefit from that short-sightedness.
Do you really believe insurance companies harassing providers and slow paying has any repercussions in their markets? Employers couldn’t care less and pretty much go with the cheapest policy they can find. In addition, injured workers have no say in these decisions or which company your employer chooses to use for their comp insurance. I know you are anti providers making a killing, but seriously, however aggregious you think some physicians and providers are there are plenty of insurance companies who have made non payment an art form. Please try to not lose sight of that when reporting on these issues.