Is anyone concerned that the constant inflation in medical diagnosis due to the demands of the insurance industry will effect medical care?
In my experience in the US, and I believe this is generally recognized, doctors have to inflate symptoms and diagnosis to get the lab tests they believe the patients need. If anyone doubts that, they haven’t been to the doctor office in the last few years. I have been a very sick person according to my doctor’s evaluations, but fortunately all the tests have come back normal. Whew. 
What I am concerned with is the possibility that new doctors or care evaluators will actually believe these claims in the charts and that will negatively effect care.
Is that something that should concern us or does everyone in the medical profession recognize and discount the written diagnosises knowing they are exaggerated to obtain lab tests and procedures?
Your post doesn’t make sense to me. Your doctor has ordered a variety of lab tests for you, all of which came back normal, but he had to lie in order (if I understand you) to get the insurance company to cover them.
What kind of tests were they? Routine screening tests, or tests for unusual conditions? While I’m glad for you that the tests all came back normal, it’s not clear to me why you needed to get them, if they were not routine screening tests. Either you had symptoms, in which case the doctor would not have had to lie, or else you didn’t have symptoms, in which case why did you get the tests?
My experience is quite different from what you describe. I have had several non-routine tests ordered by doctors, and all they had to do is to say that I needed them, they didn’t need to justify them. Certainly all routine screening tests, including colonoscopy, have been covered. Maybe one of us is an outlier, or maybe peoples’ experiences in this area run the gamut from yours to mine. It will be interesting to hear what others have to say.
But ISTM if the doctor wrote ‘pt reports symptoms similar to [disease doc know you don’t have], ordered [non-routine test]’ and the results of said test show that you don’t have whatever the doc lied and said you had, the new doc will probably not worry about it other than to keep the symptoms in mind when diagnosing something else that could be related.
Along with that, if (and hopefully when) the doc asks you about it, if you tell them that the previous doc worded it that way for insurance reasons, unless new doc is really, really green, they’ll probably understand the reasoning and believe you when you say your previous doc was never concerned that you might actually have it.
Also, don’t discount the possibility that maybe, somewhere in the back of the doc’s mind, they thought there was a possibility, even if it was a small possibility, that you may have that. At the very least, enough of a possibility that they were confident they could defend it if the insurance company declines to cover it or they get called out for it.
Reminds me of something that happened a while back. Someone I knew had a really bizarre issue with their hip. The doctor ordered an MRI and told her not to panic that he wrote down ‘possible tumor’. He said he 100% doesn’t think it’s a tumor, he just didn’t want her to have to wait weeks to get the scan, this would get her bumped to the front of the line. And, before we go any further, I’m not defending what he said, simply repeating it. Years later, I’m thinking maybe he did think there was a possibility of a tumor, but he just didn’t want her to panic for no reason.
This whole thing strikes me as nonsense. If anything it sounds like a doctor trying to appease a malingerer.
If a doctor orders a test, the test gets performed. They don’t need to submit some fluffed up justification. A good doctor’s office will check with the insurance company first to verify that the test is covered, which it usually is except for very rare or very expensive tests. On the rare occasion that the insurance company pushes back there’s probably a conversation and I would not expect many doctors to exaggerate the symptoms in such a situation, nor would they need to. If anything they’ll need to verify that they’ve done all the cheap and simple tests beforehand to confirm that it’s necessary and is the standard next step.
I think there’s probably more times when they may actually exaggerate than you might realize. You’ve got some minor excema and need some expensive cream (lets even say you did go through the step therapy and it didn’t work, but this is still getting declined), they tell the insurance company that it’s a bit more severe than it actually is.
I have a relative that gets a lot of skin tags. She learned early on, at the instruction of her doctor, exactly how to word her symptoms so as to make sure insurance covered them. IIRC, she can’t say “my necklace gets caught on them”, she has to say that they’re painful or they itch to the point where she scratches them and they bleed etc. In other words, she has to nudge the doctor to tell the insurance company this isn’t just a cosmetic issue, it’s a health issue.
True, but this isn’t about getting the test done, it’s about getting insurance to cover it.
Not just verify that it’s covered, they’ll typically get it pre-authorized. But even then, I’ve seen the insurance companies [attempt to] decline to pay after the fact. But the point the OP was making is that the doctor will trump up the symptoms in order to convince the insurance company to pay because they may not otherwise. Years and years ago I had an MRI for migraines (that I’ve been having since first grade). If my insurance company didn’t cover MRIs for migraines, this would be like them saying they were concerned about a possible tumor or other neurological issues. And, to answer the OP, if they did put that in my chart, and another doctor saw it, they’d A)probably believe me when I explained the reasoning and B)see a negative result that I don’t have a brain tumor or other neurological issue and therefore not apply it to a future diagnosis.
My old PCP used to send me for a hepatitis profile every year, solely based on the fact that I have tattoos and piercings that he imagined I had done in a back alley opium den. Heh, if only.
One year I just had enough. I pointed out to him that the phlebotomist at Quest did not follow sterility protocols as well as my tattoo artist (who is a close friend). That was it for hepatitis screening.
Warning! Crabby Old Doctor/Old Fart rant:
Doctors order too many tests. Many times it’s done to please the patient, but all too often it’s done to make the doctor feel more secure. Back in the ‘old days’, the idea was to order the test to confirm your suspicions; you already had a pretty good idea what the result would be. Now it’s more like “total body scan plus blood/urine analysis yields the following diagnoses, history and physical exam are irrelevant”.
And that’s a problem. Too many false positive tests result in further testing being needed, even though likelyhood of disease is minimal. Those followup tests are often invasive, and carry more risk. I.e. unnecessary chest x-ray shows a ‘suspicious spot’, biopsy eventually ensues, shows it’s nothing bad, but results in collapsed lung, necessitating tube in chest, 3 days in hospital, etc. etc.
(checks to see if onion is still on my belt. Yup!)
Rant over.
To clarify my OP,
In my experience the doctor (or the nurse actually submitting the lab order) essentially cherry-picks the symptoms to find the wording that the insurance will pay for. The doctor feels the test is warranted, it is just a matter of wording the lab test order to make sure insurance pays for it. I haven’t seen a doctor make up symptoms, though I don’t see nor would I understand the lab order, but I know the wording is tuned to what the insurance wants. For instance, lets say there is a joint that used to be swollen and tender and is now just tender. The order will describe the joint as swollen.
My concern is that this will devolve into the same arms race that school grades have become. A given set of symptoms isn’t keeping costs down enough so the insurance company raises the bar a bit. To get the same tests, the doctor now has to stretch the symptoms a bit further. As long as this game is just between the doctors and the insurance companies, I don’t worry about it. But it a new doctor reads my chart for the first time and sees all these serious symptoms listed, that might negatively effect my care.
Uh, are you in the US? Certainly a doctor can order any test they want to. But the lab/imaging center is going to want to get paid for that test. Unless insurance or the patient covers the cost, the test won’t be done unless it is an emergency.
A few years back when I tore my shoulder (labrum), I learned that a lot of people have torn labrums but no pain or other complications. It was only noticed during unrelated imaging. This resulted in a lot of unnecessary surgeries. It’s my understanding that nowadays, they leave it alone unless the person is having actual problems with it. They no longer pro-actively put someone through a surgery and PT for this when it wasn’t bugging them.
see my clarifications above. I don’t want this to be just about me, everyone I know has experienced similar situations. Symptoms aren’t made up in the sense that the issue doesn’t exist. But the symptoms are inflated to qualify for insurance. IE, the patient describes intermittent pain. Experience has shown that a given insurance plan won’t cover the x-ray for intermittent pain. So the lab order says constant pain. Another insurance plan covering another patient with the same symptoms will cover the x-ray for intermittent pain, so the lab order for that patient describes intermittent pain.
Crabby mild aged doctor rant on it’s way.
OP seems to conflate a few different things. First, there are CPT codes, which are the codes used for the actual visits and whatever other services the doctor provides. Then there are ICD-10 codes, which are the diagnoses codes. The latter do tend to proliferate, and in all the electronic health records I have ever dealt with, those things never disappear. There is also a tendency by some people in coding departments to add codes for every possible thing that can be added, even though that doesn’t increase reimbursement. So let’s say someone comes in to the office with less than 24 hours of having some nausea, vomiting, and diarrhea. That doctor makes a diagnosis of viral gastroenteritis, AKA stomach flu. It’s possible to code just for gastroenteritis, but there are all kinds of other codes this patient might end up with. One code for nausea, another for vomiting, another for diarrhea, another for the vague diagnosis of “feeling bad” and so on. And six months later when that same patient comes in to follow up on their hypertension and is completely over their gastroenteritis, those diagnoses codes will still pop up on many electronic health records.
The other issue, with regards to testing, does happen in some cases, and yes, it’s annoying. Let’s say someone comes in with some edema, redness, and pain to one of their legs, and the doctor wants to order a venous doppler to evaluate for a blood clot. Sure, the doctor can order the test, but I’ve run into situations where the insurance company won’t cover it for a diagnosis of “rule out DVT” or for a diagnosis of any of the various symptoms, such as erythema, edema, lower extremity pain, and so on, or even a combination of those symptoms. No, I have to put DVT as the diagnosis, even though I have yet to run the test to confirm that this is in fact what is going on. Now this isn’t an everyday occurrence, but it does happen from time to time that an insurance company will make this sort of requirement in order to get a test approved.
Since I have fantastic insurance I haven’t experienced what the OP is describing. Since I’ve have plenty of real symptoms there wouldn’t be a need for symptom inflation anyway. Because at times there was no answer to some problems associated with my kidneys doctors ordered every possible test that could help uncover an underlying cause. One of these tests checking for a genetic predisposition cost over $1800, took a while to code the order, but the insurance company paid the whole bill.
I am not surprised that doctors order procedures based on what insurance will cover, and if insurance companies aren’t covering reasonable procedures that is the actual problem. I don’t believe that many doctors are inflating symptoms to have insurance pay for unnecessary tests, devices, prescriptions, procedures, or anything else. Even with the insurance I have they all avoid calling for anything that is not medically justified.
It’s not the doctors doing it. In my experience it’s coding and billing departments. Most doctors don’t have time to look up 30 or 40 diagnosis codes on every note they write in some misguided attempt at being thorough. I personally just list the code for the specific problem(s) dealt with at that visit. Usually that’s two or three things, rarely up to 4 or 5.
The doctor’s billing department enters codes that apply. They aren’t trumping up symptoms they are just choosing from a laundry list of applicable codes. There rarely is some negotiation with some insurance agent, it’s nearly entirely electronic.
Is the billing department the one that deals with getting tests pre-approved by the insurance company (asking, really don’t know)? But even so, they’re only coding what the doctor writes, right? It’s still the doctor that writes “pain due to DVT, need venous doppler” and not “pain in legs, need venous doppler to rule out possible DVT” (based on above example), the coding dept will use different codes, but I assume they’re not the ones fudging things, the doctor is.
In most offices, yes. It’s usually the coding department to be precise, but frequently it’s the same folks in a family practice.
I think it’s wrong to characterize this as “fudging things”. This is essentially managing what has become a bureaucratic nightmare. In most cases the doctor doesn’t even need to tell the coding agent how to enter the preauthorization into the system, the coding agent will know these nuances and traps in the various insurer’s systems better than the doctor. The doctor isn’t exaggerating the symptoms or anything, they are just including the code for DVT with the test order, it isn’t really specifying that it’s the conclusive diagnosis.
Perhaps @FlikTheBlue will contradict me here, but my understanding is that these systems are all highly automated and these codes are a shorthand that don’t carry the inferences that are presupposed in this thread.
I’ve mentioned this before. Sixish years ago I was having severe chest pain that I was blowing off but that turned out to be unstable angina. Because it didn’t kill me, I thought it was GERD or some other non-cardiac problem.
My PCP freaked out and sent me to a hospital’s cardiology department where they saw that I’d had at least one heart attack. So, that’s why it hurt so much! They wanted to send me to another hospital for an angiogram/stent. I wanted to take my car, they said that was outrageous, an ambulance was the way to go and they had one idling in wait for me. I insisted on driving, but then they pointed out they’d have to remove my IVs and they’d replace them at the other hospital. I relented.
I called my insurance company to make sure the ambulance ride was covered. It was not! However, if I requested an ambulance from my home area (an hour away) it would be covered. So I waited an hour and my ambo ride was paid for. Had I not researched, it would have been an out of pocket expense.
TL/DR: Stand up for yourself. Research your options.
To elaborate on my particular situation, the vast majority of my patients are nursing home residents, either receiving long term care or short term rehab, usually after a hospitalization. A lot of the codes I mentioned that, IMHO at least, seem redundant, are placed by the facility billing department working with the therapy staff. Part of that is because of the nature of what the therapy staff are doing in terms of the treatment they provide. So from a medical point of view, the diagnosis might be something like comminuted fracture of the left distal femur. Therapy staff, however, deal with the detailed aspects of that, so they may use codes for things like loss of balance, weakness to left leg, knee pain, and so on. From a medical standpoint, it seems obvious that those are all things that come with that particular diagnosis, and that they don’t need to be stated separately. My guess is that in order for the therapy staff to bill, they do need to address those things specifically. I’m not a coding expert, and that is also a source of frustration with the way my particular practice is set up. I don’t have office staff, and in addition to the actual medical care I end up doing a lot of the back office stuff myself (which is why I have time to post on the board, the vast majority of my time is spent charting rather than in direct patient care). Every once in a while one of the insurance companies causes this type of issue with ordering a test. When that happens, I have to call and get a prior authorization and explain to the insurance company representative exactly why the test I’m asking for is indicated.