But privately-insured children with similar urgent conditions were seen in less than three weeks. For the study, research assistants compiled facts by working undercover — they posed as moms of children with seven common medical that affect large numbers of children and are serious enough to need timely specialty care: severe body rashes, obstructed breathing during sleep, Type 1 diabetes, uncontrolled asthma, severe depression, new onset seizures and a fracture that could affect bone growth. The researchers, pretending to be mothers, placed calls to a random sample of 273 clinics representing eight medical specialties in Cook County, Pennsylvania. Each of the investigators placed two calls, separated by one month, to each clinic using a script that varied only by insurance status. Only 34 percent of callers with Medicaid-insured children were told they could even get an appointment with the specialist. But if the researchers-posing-as-moms claimed they were calling about a child with Blue Cross Blue Shield PPO insurance, 89 percent were given appointments. It was obvious that how the doctor was going to get paid — whether by higher paying private insurance or by lesser paying public insurance — was of far more importance to the specialists’ offices than the severity of the child’s reported symptoms. What’s the evidence for this? In more 50 percent of calls to clinics, the caller was first asked for the child’s specific type of insurance coverage before being told whether an appointment could be scheduled with the doctor. In fact, in 52 percent of the time, the type of insurance coverage was the very first question asked. The University of Pennsylvania researchers who carried out the study noted in a press statement that previous studies have found that reimbursement amounts are the main reason doctors decide whether or not to treat patients with public insurance.
helpful resources http://www.naturalnews.com/032706_medical_specialists_children.html
Medical specialists overcharging – study
If you know that you will be guaranteed payment, no matter how much you charge, wouldnt you charge more? asked Raath. As a result of this incentive to overcharge, medical schemes are reluctant to pay out for the benefits resulting in increasing complaints from members. The registrar of the Council for Medical Schemes, Monwabisi Gantsho, said that, last year, more complaints were received about the manner in which medical schemes and administrators pay for benefits than in any other complaint category. Of a total 5 915 complaints received by the registrarCMS, 2 411 related to benefits. Of these, 846 complaints related to instances where medical schemes incorrectly funded the benefits claims at their respective scheme rates and not in full. Unfortunately, this results in members having to foot the outstanding balance of the bill. According to the medical schemes act, your medical scheme must legally cover: Your benefit conditions in full, as per the invoice submitted by the healthcare provider. Your scheme is not allowed to use your personal medical savings account to pay for benefit conditions. The diagnosis, treatment, and care of roughly 300 serious and costly health conditions fall under benefits, including 270 diseases such as tuberculosis and cancer; and 25 chronic conditions including asthma, epilepsy and hypertension. Your scheme is entitled to nominate a designated service provider such as a doctor, pharmacy or hospital as the first-choice provider when you need treatment or care for the benefits condition. If you choose to use a nondesignated service provider and it is not an emergency situation, you may have to pay a portion of the bill. If you have a condition that is classified as a benefit, most schemes require you to register for a benefit before they will start reimbursing you as per the benefits requirements. Schemes avoid payments Gantsho notes that medical schemes are not dealing with benefits in a uniform manner and different complaints bear testament to this: Some schemes have deliberately programmed their systems to fund members benefits accounts at scheme rates and then pay the balance only after the council investigates a complaint. Other complaints related to instances where schemes underpaid claims or made no payment owing to the fact that members did not use the services of the designated service providers of the scheme, whether voluntarily or involuntarily. Some members did not qualify for benefits as their treatment did not form part of treatment protocols, but some protocols were contravening the (act) in that they were not evidence-based.