In the US, hospitals are the preferred investment destinations of private equity, enticed by the limitless possibilities of cashing in on the helplessness and overwrought minds of families in distress. Inevitably it has spawned a new breed of specialists---hospital billing advocates.
That the US model of insurance-driven healthcare is hardly satisfactory is trite. The recent coronavirus pandemic tested its efficacy and found it woefully inadequate. Out of jobs, many employees were denuded of health cover for themselves and their families that came with employment. Remember health insurance is a perquisite that is assiduously negotiated in the US with its quality and adequacy going up as one goes up the hierarchical ladder.
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Health insurance companies stepped into the breach with a short duration policy to enable employees without jobs to tide over the temporary state of helplessness on the health front. But, as it happens with most of the short-term solutions and expedients, such short-duration policies have proved to be more illusory and deceptive.
The US health insurers have over the years honed claim rejection to a perfect art. Preexisting disease, exclusion clauses and what have you are the tricks to wiggle out. The hefty deduction, a euphemism for partial self-insurance, is another trick. For example, US$ 10,000 would have to be footed by the insured and per day cover is just $1,000 are the typical clauses. Employing creative interpretation, if a claim is for US$15,000, the first 10,000 is straightaway knocked off and the remaining 5,000 is examined with a fine toothcomb to see if it can be further pared down.
In India, as indeed elsewhere rushing a patient in extremis to the casualty or emergency department of the hospital is the norm. But the wily insurers discourage first aid in emergency care and even threaten rejection of the claim on the specious ground that if you are fit to reach the hospital in a family car, you could as well have gone to the family physician or pediatrician. Emergency department infrastructure and other medical paraphernalia are expensive; ergo the billing is hefty. Hence a no-go area for the insurers. And if you still went, your claim is in jeopardy!!
It is not as if the insurers alone are the villains of the piece. Hospitals too have to share a substantial share of the blame. Heavy and indecipherable billing is commonplace. We in India have been the victims of such greed and highhandedness. Doctor’s prescription has been the butt of the joke for its illegibility but a hospital’s computer-generated bill is no better. It is simply gobbledygook. Codes are used that simply are indecipherable by the layman.
In the US, health advocates specialise in niche areas. There are advocates who take on the might of the insurers just as there are medical billing advocates who decipher the bill and lay the details on the table.
Often times a red-faced hospital sues for peace by reducing the bill at the imminent prospect of losing out in the court of law. Billing for tests not done, equipments not used, medicines not administered are some of the tricks in the hospital repertoire. Heavy padding is second nature to them. The author has had the mortification of paying Rs 2,000 just for panicking at the sight of his mother’s aggravated breathlessness and summoning the pulmonologist who simply went away after fixing the oxygen tubes into her nostrils casting a withering glance at the author for trifling with his precious time. Charging for each visit by the duty doctor, shift nurses, shift ward-boys complete the recipe on how to mulct the patient and her family.
Robin Cook, the author of medical thrillers with whom the author has the privilege of powwowing from time to time is categorical that it is the private equity-hospital-insurer unholy nexus at play. Hospitals have become the private equity’s preferred investment destination with health being an emotive issue and families ready to sell their silver for the sake of their near and dear ones. Chief Medical officer (CMO) is a hospital’s lynchpin who while technically being a doctor spends the bulk of her time and energy on profit maximisation.
For this second role which marginalises her first love, she arms herself with a hospital MBA degree. The private equity firm cossets such an ebullient CMO with fabulous and mind-boggling salaries with stock options thrown in. Cook says that CMO is actually the CEO because these hospitals have the Chief of Internal Medicine and Chief of Surgery the pure medical experts in any case.
India too has set store by health insurance with the Modi government launching the Ayushman Bharat initiative a couple of years ago providing free healthcare to some 50 crore BPL people. It is an insurance-driven model that proved woefully inadequate especially during the second wave in the first half of 2021. Of course, the primary reason was oxygen short supply but the American lessons cannot be lost on us. We should actively promote the idea of hospital billing audit that must swing into action at the instance of the patient at no cost to her. Of course the well-heeled can afford the services of hospital billing advocates.
In the US medical billing advocates offer their services for a percentage of the bill amount reduced in keeping with the US law that allows result-based remuneration for advocates so much so that compensation claims are often instituted by advocates motivated by a sliver of such claims. But in India advocates are not allowed to charge result-oriented fees. That is why hiring hospital billing advocates may be beyond the reach of common folks unless the government picks up or subsidises the tabs.
— S. Murlidharan is a CA by qualification and writes on economic issues, fiscal and commercial laws. The views expressed in the article are his own.
Read his other columns here.
(Edited by : Ajay Vaishnav)