Physician Manipulation of Reimbursement Rules for Patients
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Open Access
- 12 April 2000
- journal article
- research article
- Published by American Medical Association (AMA) in JAMA
- Vol. 283 (14) , 1858-1865
- https://doi.org/10.1001/jama.283.14.1858
Abstract
Physicians' decisions about what services to offer their patients affect almost 80% of all health care expenditures and have an enormous influence on health care quality.1,2 To control cost and quality and ensure adherence to their contracts, health care delivery organizations and payers frequently review physician recommendations and pay for services (eg, diagnostic tests, drugs, or hospitalization for treatment) only in predefined circumstances. This utilization review may occur prospectively, in the form of preauthorization; concurrently, requiring immediate approval over the telephone; or retrospectively, with payment decisions being made after services have been delivered. Specific utilization review criteria are rarely spelled out in advance; what physicians agree to when they sign health plan contracts varies greatly and may both alter and constrain physicians' decisions regarding their patients' use of services.Keywords
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