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PubMed1997

Spying at work.

Explore the source record for details and available documents.

Employment↗
PubMed1997

Defining and implementing medical necessity in Washington State and Oregon.

This paper reports on a qualitative study of how health care providers in the states of Washington and Oregon define and implement medical necessity. Based on a series of semi-structured interviews, we found that few insurers or health care plans in our sample attempted to resolve the ambiguities inherent in defining medical necessity. More importantly, our results suggest that physicians in managed care plans were not using general definitions of medical necessity to make clinical decisions, but instead relied on utilization management techniques to guide the use of medical resources. We conclude that medical necessity as an organizing principle for clinical practice decision making is likely to continue to erode in a managed care environment.

Decision Making, Organizational↗
PubMed1994

Dental fraud. A dental consultant's view.

Since most plans today are based on "cost plus", employers and unions, whose plans were negotiated a long time ago, cannot afford to pay an increase of $13 per amalgam as they were asked to do when new codes for bonded amalgams were added to the provincial fee schedule. Similarly, demanding strains were placed on drug plans when a $16 per tablet medication for migraine headaches was placed on the market. The plan says that if a physician prescribed it, it will be covered. But by whom? And for how long? Dental insurance is not, and has not been for a very long time, a source of profit for the insurance carriers. One large company, for whom I worked for a number of years, just sold all their group dental insurance to a large carrier. Another well-known company has placed their group insurance on the market and is anxiously seeking a purchaser. It is too much to ask of a dental plan (and let's face it, without the plan, the patient may not seek dental treatment) to pay $100 or more for an "examination and one periapical radiograph resulting from the referral of a patient by a general practitioner to a specialist for endodontic treatment." In the case of a difficult diagnosis, this might be entertained, but why charge this fee in every case, even when the patient is holding a radiograph? I am not suggesting that fraud is being committed by a large number of practitioners on a regular basis. At the same time, I think that we must realize that this type of activity may result in the removal of dental "insurance" from the benefits provided by companies to their employees. Most dentists are extremely honest, but the backlash produced by the few who are involved in fraudulent practices is disturbing.

Fraud↗