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PubMed1997

Is contingency-fee consulting an endangered species?

Consulting firms that assist hospitals in optimizing Medicare and Medicaid reimbursement sometimes charge contingency fees for their services. These fees are based on a percentage of the increased revenue they can help a hospital capture. Although contingency-fee arrangements are not considered unethical, they can result in illegal billing practices because consulting firms may be tempted to up-code to increase their fees. The 1994 investigation of Metzinger Associates, Voorhees, New Jersey, a consulting firm providing services to 200 hospitals in 17 states, found evidence of illegal billing practices and resulted in a complaint filed by the United States Attorney's Office. Several hospitals were named as defendants. A Fraud Alert issued by the HHS's Office of the Inspector General earlier this year indicates the government intends to target consulting firms that charge contingency fees. Before engaging consulting firms that charge contingency fees, hospitals should carefully evaluate each firms to determine whether its recommended billing submissions will be accurate, credible, and defensible.

American Hospital Association↗
PubMed1999

["Thus it passes from the patient's purse into that of the doctor without causing displeasure" - Samuel Hahnemann and medical fees].

In 1834, Hahnemann gave the following advice to his pupil Dr. Karl Julius Aegidi: "We are not allopaths who have high medical fees and can legally demand high sums for evil deeds. We must take what we have earned on the spot, since we are not considered worthy of ordinary justice." In an earlier letter to the same addressee, Hahnemann wrote: "No one enters my house if he does not have with him the money to pay me, unless he is paying me monthly, in advance [...]." There can be no doubt that in Hahnemann's times, fees were the most important component in a physician's income. Dependency on fee income meant that the physician always had to worry about delayed and even avoided payments, and patients' reluctance to pay was notorious. Many doctors lost large parts of their nominal income through bad debts. In some cases, installments were accepted by both parties, to avoid costly legal action, which were usually a last resort. In these circumstances it is hardly surprising to find Hahnemann, the founder of a highly disputed new cure, stressing to his colleagues that for a successful medical practice, cash payments at the time of treatment or in advance were preferable to post-facto bills. Having been ostracized by the medical establishment, Hahnemann showed a remarkable professional awareness of patients' propensity to debt. Long before regular physicians propagated cash payment, Hahnemann derived his income solely from ready-money payments. However, he used a sliding fee structure to allow for the different economic circumstances of his patients, who came from all walks of life. The very poor he treated for free, while members of the rural and urban middle class had to pay considerable fees. In some cases, Hahnemann was able to charge very high fees, and his numerous enemies used this against him.

Fees, Medical↗
PubMed2002

Registration and reregistration application fees. Confirmation of final rule, remanded for further notice and comment, and response to comments.

DEA is publishing a final rule regarding the registration and reregistration fees charged to controlled substances registrants. DEA is required to charge reasonable fees relating to the registration and control of the manufacture, distribution, and dispensing of controlled substances. To address this mandate, on March 22, 1993 DEA published a final rule in the Federal Register, establishing registration fees for controlled substances registrants (58 FR 15272). Following publication of the final rule, the American Medical Association (AMA) and others filed a complaint in the United States District Court for the District of Columbia objecting to the new fees. The district court issued its final order granting the government's motion for summary judgment and disposing of all claims. The AMA appealed. The United States Court of Appeals for the District of Columbia Circuit found DEA's rulemaking to be inadequate. The appeals court remanded, without vacating, the rule to DEA, requiring the agency to provide an opportunity for meaningful notice and comment on the fee-funded components of the Diversion Control Program. DEA responded to the remand requirement through a document published in the Federal Register on December 30, 1996 (61 FR 68624). This Final Rule supplements the December 30, 1996 Federal Register document and with that document, constitutes the final rule on the Drug Diversion Control Fee Account.

Congresses as Topic↗
PubMed1991

Fees charged to a consulting population in general practice.

OBJECTIVES: information generated by the computer systems of thirty-five general practitioners was examined to determine their fee structure during the study period. METHODS: copies of the general medical services (GMS) claims and patient fees were examined to determine whether patients had been charged the doctor's regular fee or an amount greater or less than this. RESULTS: information on 97,869 consultations was collected. A regular fee was charged to patients in 47% of cases, a greater or less than normal fee was charged in 7.5% of the consultations, and no fee to the patient was made in 22.5% of cases. Consultations charged to the Accident Compensation Corporation (ACC) comprised 17.5% of the study data. Maternity cases comprised the remaining 5.5%. Nineteen doctors provided information on 6511 out of hours or home visit consultations. In 44.3% of these cases no charge was made to the patient. This proportion was higher among beneficiaries (58.9%) than for any other group. CONCLUSION: all of the contributing doctors appear to exercise discretion in their charging policies rather than to maintain a rigid pricing structure for their services.

Adult↗
PubMedDate not supplied

Fee structure as a determinant of patient's choice to undergo mammography.

Mammography, although an effective screening tool, has generally been underutilized. Although many factors may contribute to low utilization rates, the degree to which fee structure influences women's decision to have mammography has not been determined. This study compared women having mammography at the regular fee with those women having mammography at a special reduced rate. The study group consisted of all women having mammography for eight consecutive months at a new mammography screening clinic. The clinic had specifically been established for self-referral. Women from both groups when compared to the general population in the surrounding area tended to be in a higher educational/socioeconomic level. Women in the regular fee group reported physician influence as being most important in their decision to have mammography while women in the reduced fee group reported the reduced fee of mammography itself as the most important factor. Books and magazines were the second most important factor for both the regular and reduced fee group with regard to their decision to have mammography.

Adult↗
PubMed1987

Physician reimbursement by salary or fee-for-service: effect on physician practice behavior in a randomized prospective study.

We used a resident continuity clinic to compare prospectively the impact of salary v fee-for-service reimbursement on physician practice behavior. This model allowed randomization of physicians into salary and fee-for-service groups and separation of the effects of reimbursement from patient behavior. Physicians reimbursed by fee-for-services scheduled more visits per patient than did salaried physicians (3.69 visits v 2.83 visits, P less than .01) and saw their patients more often (2.70 visits v 2.21 visits, P less than .05) during the 9-month study. Almost all of this difference was because fee-for-service physicians saw more well patients than salaried physicians (1.42 visits and .99 visits per enrolled patient, respectively, P less than .01). Evaluating visits by American Academy of Pediatrics' guidelines indicated that fee-for-service physicians saw more patients for well-childcare than salaried physicians because they missed fewer recommended visits and scheduled visits in excess of those recommendations. Fee-for-service physicians also provided better continuity of care than salaried physicians by attending a larger percentage of all visits made by their patients (86.6% of visits v 78.3% of visits, P less than .05), and by encouraging fewer emergency visits per enrolled patient (0.12 visits v 0.22 visits, P less than .01). Physicians' interest in private practice, as determined by their career plans, correlated significantly with total number of patients enrolled (r = .48, P less than .05) and total clinic patients seen by each resident during the study (r = .40, P less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1972

Physician fee indices in California and the U.S. through June 1971.

California physicians' fees increased 2.2 percent in the first half of 1971, according to figures compiled by the Bureau of Research and Planning. Nationally, physicians' fees increased at a faster rate of 3.4 percent during the same period. This was the slowest semi-annual increase in the California Index since the final six months of 1968 when fees increased only 2.0 percent. A decline was also recorded in the rate of price increase for other goods and services in the first half of 1971. Nationally, the "all items" increase amounted to 2.0 percent, and the service component rose 2.1 percent. Also included in this Report is special information on the charging patterns of physicians for office and hospital visits and data on physicians' fees in the Los Angeles and San Francisco Metropolitan Areas. The California Physician Fee Index is a continuing survey conducted by the CMA Bureau of Research and Planning since 1962. The survey questionnaire which lists 26 medical, surgical, radiological, and laboratory procedures, elicits fee information from approximately 1,000 randomly selected physicians. Since June 1970, the procedures on the questionnaire have been listed according to the coding nomenclature used in the 1969 edition of the Relative Value Studies, published by the California Medical Association. Prior to that, the 1964 edition was used to delineate the procedure being surveyed.

California↗
PubMed1982

The contingent fee: disciplinary rule, ethical consideration, or free competition?

The contingent fee deserves a place in American legal practice because it provides an efficient means of financing legal services. Moreover, its general acceptance by the American legal community probably assures its continued use. Nevertheless, its use creates the possibility of abuse by the legal profession. To guard against possible abuse a lawyer should: (1) Fully and specifically disclose to the client all relevant considerations, including the existence of potential conflicts of interests and the composition of the particular fee, before entering into any contingent free contract. (2) Always reduce a contingent fee contract to writing and submit a copy to the client; (3) Adjust the fee to reflect the risks of each case rather than apply the same percentage to all cases; (4) Resolve all conflicts in the client's favor; and, (5) Make necessary adjustments to prevent unexpected windfall profits. In addition, all lawyers should seek new methods to make legal services affordable by all. If followed, these proposed guidelines should help to overcome some of the abuse incident to the use of contingent fees. Preventing that abuse will assure that the contingent fee can continue to be beneficial in many respects to both lawyers and consumers of legal services.

Canada↗
PubMed1993

Calculating the GP consultation fee in Singapore: towards a rational costing approach.

PURPOSES: The General Practitioner (GP) consultation fee in Singapore, unlike that of his specialist colleague, has been left very much undefined over the years. There is a need for an objective way of calculating the GP consultation fee. METHOD: A proposed method of calculating the GP consultation fee based on the model of estimating the total cost of producing the service plus the doctor's remuneration is described. Known prevailing costs were used in the computation. This model allows us to work out the cost to the patient by dividing the total cost of producing the service by the number of patients (referred to as patient encounter load) seen by each duration of consultation--4, 6, 10, 15 and 30 minutes. Different monthly remuneration levels for the doctor were used to compute the different consultation fees that would result for each of the duration of consultations. RESULTS: Using this method of calculation, for a doctor with a desired monthly remuneration of $7000, and seeing a patient every 6 minutes over a 150-hour month, the consultation fee is $13.00. This drops to $11.00 if the doctor receives a remuneration of $4000 per month. Using the same parameters, a 15 minute consultation will cost the patient $30.00 and $25.00 respectively. CONCLUSION: This method can be used to derive a consultation fee for services requiring different durations and varying remuneration brackets for the doctor.

Capital Financing↗
PubMed1990

A comparison of quality in a dual-choice dental plan: capitation versus fee-for-service.

The quality of dental care provided under a dual-choice dental plan was evaluated. Eleven practices, six capitation and five fee-for-service, were examined. The methodology was based primarily on examination of elements of structure and process of care. Samples of patient dental records were drawn from each practice for a total of 495 patient records. The results showed that none of the five fee-for-service dental practices and only two of the capitation practices were found to meet all the criteria for acceptable dental practice. Universally poor documentation made it extremely difficult to evaluate process measures of care. Fee-for-service patients received more visits and services than capitation patients. Overtreatment occurred in fee-for-service practices and undertreatment occurred in capitation practices. The distribution of services also differed, with capitation practices providing a less expensive type of service. Annual utilization of one or more services for capitation practices varied substantially by the practice. In this plan, both capitation and fee-for-service practices demonstrated a need for strong quality assurance mechanisms to protect the interests of patients.

Adolescent↗
PubMed1996

The Prescription Drug User Fee Act of 1992. A 5-year experiment for industry and the FDA.

The Prescription Drug User Fee Act of 1992 authorises the US Food and Drug Administration (FDA) to collect in excess of $US332 million in user fee revenues over a 5-year period. Not only did Congress determine that the revenues would be dedicated to expediting the FDA's review of human drug applications, the FDA articulated formidable time-specific performance goals to be achieved by fiscal year 1997. At the mid-point in the 5-year programme, the FDA reported that it had met or exceeded its performance goals. In this article, we review the history of the user fee scheme in the US, outline the details of the legislative provisions, and discuss the challenges confronting the agency as it works to simultaneously meet the user fee goals and respond to political forces calling for substantive FDA reform. User fees loom large for the global pharmaceutical and biotechnology industries as economic pressures force a number of countries to consider shifting a portion of the cost of regulatory review to the regulated industry. This article provides a reference on the US framework and may be useful in future international comparisons as the user fee phenomenon spreads.

Drug Industry↗
PubMed1996

The effect of capitated and fee-for-service remuneration on physician decision making in gynecology.

OBJECTIVE: To evaluate the variations in physician behavior leading to performance of gynecologic surgical procedures related to fee-for-service and capitation reimbursement systems. METHODS: This study compared the physician practice utilization of surgical services for fee-for-service and capitated contract reimbursement systems within a gynecology clinic. Attending gynecologists were reimbursed on a fee-for-service basis for all surgical services performed during a 6-month interval; subsequently, the same physicians were reimbursed on a capitated basis for 6 months and received a fixed payment for the clinical and surgical services provided. RESULTS: Three thousand seven hundred eighty consecutive outpatient gynecology visits were evaluated at the university gynecology clinic during 1994. We found a 15% overall decrease in the number of surgical procedures that were performed during the capitated reimbursement period compared with the fee-for-service time interval. The procedure most responsible for the reduction of surgical services was elective sterilization by laparoscopy, which underwent a statistically significant decrease (P < .01). CONCLUSION: The remuneration system in our review seemed to affect physician decision making for only the most elective procedures, whereas physicians maintained similar practice patterns for more severe conditions. Fee-for-service seems to encourage, whereas capitation seems to discourage, gynecologist from performing elective procedures.

Adult↗
PubMed1979

Paying the physician's fee: Blue Shield and the reasonable charge.

At a time of debate over physicians' fees and income, we describe the evolution of Blue Shield plans and programs to pay physicians' fees. We review how Medicare's "reasonable-charge" formulas fostered Blue Shield "usual, customary, and reasonable" (UCR) contracts. In a three-year period in the Washington, DC, area, Blue Shield UCR protocols permitted "customary" allowances for selected surgical procedures to rise 29 to 75 per cent; charges by two physicians increased allowances for coronary-artery bypass from $2000 to $3500. We find little justification for secrecy in fee-payment protocols. Physicians dominate the District of Columbia Blue Shield Board and its committees, and they control fee-payment formulas. Nationally, 61 per cent of Blue Shield boards have majorities of health-care providers; approximately two thirds of fee-related committees have physician majorities. We urge increased public debate, public representation, and accountability in monitoring and reforming the programs that we describe.

Blue Cross Blue Shield Insurance Plans↗
PubMed2000

Survey of dental fees charged by dentists in Singapore.

A survey on dental fees was conducted among all private dental clinics registered with the Medical Audit and Accreditation Unit of the Ministry of Health in Singapore. Replies were received from 74 dental clinics. Analysis of results showed that there was a general increase in the median of fees charged in 1998 compared to the fees listed in the Minimum Fee Schedule issued by the Singapore Dental Association in 1994. 93% of the respondents indicated that there is a need to revise the Minimum Fee Schedule.

Fee Schedules↗
PubMedDate not supplied

Relative fees and the utilization of physicians' services in Canada.

STUDY QUESTION: The study objective is to estimate the relationship between changes in the relative fee physicians receive for a procedure and the utilization of the procedure. DATA SOURCES/STUDY SETTING: The study uses claims-based, procedure-specific, quarterly, aggregate utilization data for physicians in three specialties and four provinces in Canada for the period 1977-1989. STUDY DESIGN: The unit of analysis is an individual procedure. Multi-variate regression methods for cross-sectional/times-series data are applied to estimate the utilization-fee relationship while controlling for supply- and demand-side determinants of utilization. PRINCIPAL FINDINGS: There is no evidence of a strong, uniform utilization response among the 11 procedures analyzed. The results include a mixture of significant and non-significant fee coefficients, and among the significant coefficients, a mixture of signs is observed. The results are consistent with utility-maximizing behaviour by physicians rather than with profit-maximizing behaviour. CONCLUSIONS: The fact that the direction and degree of the utilization effect associated with changing fees is procedure-specific has direct implications for our ability to develop effective policies to modify physician behaviour that are based primarily on financial incentives, particularly those based on manipulating fees. The study also highlights the limitations of analyses based on aggregate data and suggests methodological approaches that have potential to overcome some of these limitations to fill gaps in our current knowledge.

Canada↗
PubMed2006

Managing for desired experiences and site preferences: the case of fee-fishing anglers.

Fee-fishing involves paying a fee for the privilege of fishing a body of water where fish populations are enhanced by stocking fish. Past literature on this activity has focused more on the operation of the enterprise and management of the fish than the people and site characteristics. The objectives of the study were to profile anglers and describe their site/management preferences. This study utilized an on-site interview and mail-back questionnaire at fee-fishing establishments in West Virginia (n = 212). Factor analysis of desired recreation experiences yielded five factors: Experience nature & adventure, Stress release & relaxation, Trophy fishing, Escape, and Family time. Cluster analysis showed that these anglers can be segmented into two distinct clusters, differing by sociodemographic characteristics, fishing behavior, and site/management preferences. The findings from this study provide baseline data to aid public resource managers and fee-fishing business owners in determining how to provide satisfying outdoor experiences and deliver desired services on-site. Future research will be needed from additional fee-fishing sites to obtain more detail about this outdoor recreation cohort and be able to generalize to a larger population of participants.

Animals↗
PubMed2006

Medicare fees and physicians' medicare service volume: beneficiaries treated and services per beneficiary.

Using merged physician survey and Medicare claims data, this study analyzes how fee levels, market factors, and financial incentives affect physicians' fee-for-service Medicare service volume. We find that Medicare fees are positively related to both the number of beneficiaries treated (eta = 0.12 to 0.61) and service intensity (eta = 1.04-1.71). Physicians with apparent incentives to induce demand appear to manipulate the mix of services provided in order to increase the effective Medicare fee. Finally, several market factors appear to influence the quantity of Medicare services physicians provide. Results highlight limitations of the present system for compensating physicians in Medicare's fee-for-service program.

Aged↗
PubMed1985

Are adolescents able and willing to pay the fee for confidential health care?

We studied the ability and willingness of adolescents attending a suburban-based Adolescent Health Service to pay a fee for health care. Self-administered, anonymous questionnaires were distributed to 180 predominantly middle-class adolescent patients prior to the establishment of a fee-for-service payment plan. One hundred sixty-five respondents planned to continue as patients of the Adolescent Health Service; of these, 155 (94%) indicated that they would be able and willing to pay a fee. All of the 155 respondents indicated they could pay $5 per visit, two thirds could pay as much as $10, half could pay $15, and one fifth could pay $20 or more. Sources of fee money would be job earnings, a friend, allowance, and savings; 75% of respondents planned to pay without any help from parents. Analysis revealed few significant correlates of ability and willingness to pay with demographic, socioeconomic, and attitudinal factors. These data demonstrate that, although few of these middle-class adolescent patients indicated that they were able and willing to pay a full fee of $20 or more, most were able and willing to pay more than a token amount for health care.

Adult↗