Thursday, August 25, 2011

Contingency Fee for Physicians

"We've already established what you are, ma'am. Now we're just haggling over the price." - George Bernard Shaw

The debate rages: Should physicians charge a fee for non-clinical tasks such as completing FMLA and disability forms, utilization (peer) review, and prior authorization for reimbursement for drugs, tests and procedures? As physician reimbursement plummets physicians increasingly wonder how they will pay the overhead, much less take home enough to pay off the student loans and still make a living. Many physicians now charge a nominal fee, maybe $50, or an hourly rate which barely covers the loss of time entailed.

Keep in mind that in many cases a third party like a disability carrier or pharmacy benefit manager exploits the physician's wish to help the patient in order to obtain free service from the doc. Physicians rarely obtain payment from the third party, and billing the third party raises ethical and role questions. The physician should work for the patient, but the third party foots the bill. Who does the physician work for anyway? And yes, the same question arises when the physician accepts money from insurers for rendering ordinary medical care, especially under contract.

Plaintiff's attorneys can collect as much as 30% or more of damage awards as contingency fees when they win a case. Not only does this practice assure an income, it also provides an incentive for them to take a case and spend their own money on trial expenses, like hiring expert witnesses, that many of their clients cannot afford.

Why don't physicians do the same? Let's say a patient applies for disability, and the policy allows for $1000 per month. If the physician completes the application, but the carrier rejects the claim, no one pays the physician either. But if the policy is awarded, the physician takes 30%, or $300 per month. It could work the same way for prior authorization for an expensive new atypical anti-psychotic. The physician would take 30% of the retail price as a reward for having obtained reimbursement.

This could change the game, giving physicians an incentive to increase skill at obtaining reimbursement. Experts with proven track records would sponsor courses. Physicians would publish their success rates on their Web sites. Patients would choose physicians, not by bedside manner or quality of medical care, but instead by how well they perform to obtain reimbursement.

What? You say there may be an ethical problem with this approach?

"We've already established what you are, ma'am. Now we're just haggling over the price." - George Bernard Shaw


  1. In your example, the disabled person is eligible for $12,000 a year, and you propose a 30% contingency fee? I am sympathetic to the income pressures on physicians, but apparently you have never tried to live on less than $12,000 a year (except maybe as a student, but you knew it wouldn't last forever). If the person gets a lawyer, the lawyer will take their 30%, so the patient is left with - $400 a month, in your scenario? Try living on that. I think you didn't think this scenario thru.

    My doctor helped me with my disability case, but put FAR FAR less time into it than a lawyer would have, if I could have afforded to hire one. But a lawyer will not take a case for a person who is low income. They only take disability cases for people who are disabled lawyers or doctors (in the case of private disability insurance covered by ERISA). Social Security is a different beast, but again, my docs put little effort into it, in fact, maybe none besides their staff photocopying medical records which nowadays, I probably would be charged for that. I certainly was charged for the records I got for the private disability insurance company. My therapist and social worker folks put unpaid time into it too, more than my doctor. I can see where this is going. . . go on disability, and PAY for the privilege.

    some of the disability companies hassle the doctors on purpose, because they are trying to get the doctors to give up on that patient, so then the patient has no advocate, and the disability company can then say there is little medical evidence, and deny the claim. Lawyers say this on their blogs, and I don't know if it is true.

    I would have paid my doctor for the time spent on my paperwork, but it really wasn't very much time, and I wasn't billed. My doc worked in a big clinic, so I dunno how that would be arranged anyway. I sent my doc a nice flower arrangement instead, because I really do appreciate the time and effort and support.

    I want to sum up that I know a lot of people who are profoundly disabled by mental illness, and most of them could never have coughed up enough money to pay a physician to fill out their disability forms. the only reason that I would be able to is that I am married and my husband has income. I wonder if a lot of your patients are much less mentally ill than the folks that I know, and taking short term disability for stress. The reason I know so many disabled folks is because of programs that the county social services program puts on for seriously mentally ill people, so maybe we are the very sick ones and not typical. Most of the folks I know who are on disability would not have been able to afford to send flowers to those who helped them, either.

  2. CatLover: Thanks for the comment. Am sorry to hear of your difficulties. Actually I am not seriously proposing the outrageous scheme I described. I am opposed to treating physicians assessing their own patients for disability for any fee or for no fee. Your doc should focus on treating your illness, not on getting you money.

  3. I am not so thrilled with the current system either, because then I feel (correctly) that my treating psychiatrist has control over my paycheck and it intimidates me.

    After being treated dishonestly by my private disability insurance company a few years back, now I am afraid to even say anything to my treating physician, for fear the insurance company will cherry pick thru my records, which they did maliciously.

    So in the system we have now, I am afraid of my doc because I fear commitment, and afraid of my doc because the doc might refuse to do paperwork, which one doc did, because he didn't want to take the time (real shortage of psychiatrists in my state, and especially my rural area). Or the doc can just make the "mistake" of writing the treating notes for their own reference, without paying attention to the risk that a dishonest insurance company will cherry pick records.

    It would be much better to have an independent doc fill out my paperwork, but the insurance company wants your treating doc to handle it. If you had to hire a forensic psychiatrist to do it, they would be suspicious.

    Because the insurance companies get to call the shots, or social security, I don't think that patients or doctors can do anything about it. Those doctors who refuse to do this paperwork risk putting their patients on the street for lack of income.

    Sorry I missed your tone on this proposal - there is so much talk on various blogs, slamming disabled people lately, that I am getting defensive about it and not reading carefully enough.

  4. No need to apologize. My writing can get sarcastic. I think more (all) docs should refuse to evaluate pts for disability. Docs who refuse also risk losing income if they put the patient on the street, so there's a conflict of interest: If I say your disabled, I keep getting paid to treat you, if I say you can work, I lose a patient. Duh.

    If anybody has to hire a forensic psychiatrist is should be the insurance company, never the insured.

  5. The SS disability forms are biased to engender answers supporting no disability. I've done exams and reports that take 3 to 6 hours. Of course I charge for my time. And when I believe that the people are disabled (otherwise I cut the exam short, still charging for my time)the reports are bulletproof.
    by TimeIsMoney