No charity allowed

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Her job is to assure that doctors and nurses do not commit random acts of kindness. Her effectiveness is confirmed by a massive new Robert Wood Johnson Foundation-funded study of 6,600 physicians that found only 68 percent of doctors now say they deliver any free or discounted assistance to low-income patients, down from 76 percent a mere 10 years earlier.

Has raw capitalism crushed medical compassion? The liberal foundation and its Center for Studying Health System Change presumed so but were at a loss explaining the decline -- citing tight schedules and medical school debt, as if these were new phenomena that could explain the change. They came closer to the cause in pointing to lower physician reimbursements but they only mentioned private insurers, altogether blind to the main culprit.

Admittedly, the cause was not obvious. It was a case of the student teaching the professor. Although he had managed the largest employer health insurance plan in the nation and written often on health matters, this medical neglect had escaped the professor's notice. The student had informed him she worked for a medical practice and was hired to keep the firm's health professionals from defrauding the government.

It seems that Medicare and Medicaid consider it fraud if a physician charges any patient less than the government must pay for a medical service. If a doctor feels compassion for some poor soul and offers a discount, he must grant that "discount" for every billing for every patient in the government programs. If he forgives one indigent from paying at all, the government never has to pay for any such procedure. The only reason the study shows so much charitable activity is that the physicians counted extra time spent at hospitals treating indigents as charity, which it really is not since treatment is required by law.

She wrote: "I am employed as a Coding and Compliance Manager. Along with supervising nine people, I perform audits on the physicians billing, credentialing, coding, collections, and directly supervise charge entry, posting payments, pre-certifications and referrals. Many people think that physicians only have to treat patients. Because the government has such control over healthcare they need to hire people who specialize in keeping their practice running according to the government standards and expectations. The government tells us how we are to handle collecting personal payments from patients. For something that sounds so small, their morals and values and mine are questioned daily.

"God help us if we inadvertently write off charges or perform services that Medicare doesn't see medically necessary and bill the patient without an advance beneficiary notice (ABN) signed. The average citizen does not understand basic health insurance let alone all the rules and regulations surrounding it. So for them it is hard to understand why we cannot just write off their balance. They think physicians are money hungry. There are so many rules and regulations that are constantly changing there is really no way to keep up. Once you think you have it down something somewhere changes or is in the process of changing. I fear government in these instances. If I were to ever be audited and missed something my physicians would be at risk of huge fines and even jail. I then would be out of a job no questions asked. I do not believe that we have much control over our government as we are sometimes led to believe."

When one reads about doctors being hauled off to jail for fraud, odds are this is the cause: guilty not of fraud but of charity. If a health provider bills for either government program, it is subject to a federal audit. Every patient's record, whether Medicaid or Medicare or not, is scrutinized to assure that no non-government patient pays less than the government. A physician can fill out paperwork for an exception but who will take the time or the risk? If the health provider gives anyone an undocumented break this is "fraud" and it is off to jail for the foolish Mother Theresa.

The decline in charity by physicians documented in the study is guaranteed to get worse. It shows that most charity is performed by doctors working in small practices. Large practices already hire people like the student to assure they commit no charity. As the smaller practices become aware of how the government operates, they will perform fewer charitable acts.

The unique American attribute of private and local charity that has so amazed the world since the French observer Alexis de Tocqueville described it so vividly in the early 19th century will soon be regulated away, leaving a world for our children and grandchildren where it will be impossible to give free medical assistance for fear of being accused of fraud.

Donald Devine is a professor of political science at Bellevue University and was director of the Federal Employees Health Benefits and Civil Service Retirement programs during President Ronald Reagan's first term.