Doctors Win Billing Bout with HMO
Special Managed Care Bulletin
Hi, everyone. Here's an article you may find interesting. It's from my state, Florida, and describes United Healthcare's use of computer software to automatically downcode claims.
Doctors win billing bout with HMO
Monday, May 31, 1999
Susan Lundine, Staff Writer
ORLANDO -- Faced with angry doctors threatening to jump ship, United HealthCare of Florida will dramatically reduce the number of medical claims automatically "downcoded" by its software program.
Downcoding involves paying doctors based on an insurance code representing a brief or uncomplicated office visit -- even when the actual visit involved a great deal of time and care. Thus, a doctor who spent an hour with a patient suffering from a serious or chronic illness, such as HIV infection, might be paid a lower amount normally charged when he treats a patient for a bad cold.
The software, Patterns, has been used by United HealthCare in other states. However, company officials used the software on a much larger scale in Florida, according to a United HealthCare executive quoted in American Medical News, a publication of the American Medical Association.
Within four months of the software's introduction here, the Florida Medical Association formally asked that the state Department of Insurance investigate United for downcoding. The state subsequently launched an inquiry, which is ongoing.
Meanwhile, some local physicians angered over the issue refused to treat patients covered by United HealthCare.
Fred Dunlap, president of United HealthCare of Florida, defended the software. "If you had a car looked at and you get a bill without a description of what they did, you would question what the money is for," he argued "Patterns asks for more complete information that supports the (doctor's) claim for reimbursement."
However, a spokeswoman for United now says the company has "been continuing to review how they use Patterns. I know they're making adaptations."
In fact, the software now will be used to review the bills of fewer than 100 Florida doctors -- those identified as asking to be paid the highest rate possible for most of their patients' office visits.
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