No medical system charges the average patient as much--legally--as the U.S. system does. When it comes to ethics vs. legalities of patient payments, U.S. doctors have the shortest legs in the world to stand on.

The French system, for all the praise it gets in the U.S., is a fiscal mess. That system does need to find a way to charge their patients more, or it will eventually go bankrupt. Conversely, the U.S. system needs to find a way to charge its patients less.

> Medicine isn't a business.

but the reality is that it's a very big business, otherwise these discussions about how to 'game the system' for profit wouldn't exist.

not trying to disrespect either one of you, just making an observation.

Really, it's legal in France. We have a mixed public and private for-profit system. And studies have revealed a tendency to underbill - ie forget codes.

FYI, I am licensed, board member, and I do see patients.

However I strike a line between patient care and billing analysis. And I love both.

For patient care, my consults are provided for something like $30/consult. Keep in mind these are lengthy consults (~30/45 min per patient) in a demanding specialty. I do them far below costs, in a public hospital, to help - because I know how much the only alternatives in town costs.

For billing analysis, however that's another story. If it is legal (as in allowed by the law and the code of deontology) it goes.

But given your message, there might in fact be a language difference. I'll try to clarify my terms.

Regarding "unqualified personnel", I call anyone who is not a nurse or a practicing physican "unqualified". Ex: a medical coder or medical secretary. They do not see patients, so they are "unqualified". I see it as a good thing if they can do this work, considering the alternative is putting someone "qualified" (ie who could be with a patient providing actual medical care) on an administrative job, something that worries me as a waste of rare resources. If it actually improves the profit margin, that is great : it will provide excellent arguments against wasting rare resources! Anyway, that doesn't make a lot of differences. The laws might be different in the US than in France, but here physicians are legally personally responsible for anything the law call their "subordinates" do. Your nurse leaks medical info about a patient? Your fault by default, unless you can prove otherwise.

Regarding "massaging the bill", that's not the language I use, but it seems to be what the other poster was using. I guess that's how it's called in the US. If it has a negative connotation, I'm sorry. I personally call that billing analysis. There is no need to do anything shady - it would be stupid to do so, given how profitable just following the law can be.

Regarding "tests", it is not about exposing patients to the risks of certain tests - however, if the tests have already been performed and adding them to the bill results in a higher bill, it's about making sure they are not forgotten in the bill. Just like preexisting conditions.

The laws in the US might also be different, but here it's the prescribing physician responsibility to order tests and exams. Billing happens after the patient has left, and therefore can't directly influence the patient care ex post facto.

The medicare inspired system was adopted in France for a lot of reasons - including to help standardize care a little more.

I have had a patient I send to an hospital for chest pain in an ambulance with a case highly suggestive of infarction leave the hospital without troponin, even while he had a antecedents. I've had a patient I personally brought to the ER (we call that medical transfert) with a diagnosis of pulmonary embolism and a prescription for nuclear medicine returned after an echography and a written note saying 'there was no embolism' (how can you tell that with an echography???) - and subsequently dying of pulmonary embolism.

IMHO, this is totally unacceptable - I came to that conclusion, when as a patient I also experience such grave inefficiencies, with consequences. Some people will try to slither their way out of responsibility and consequences.

I take a great pride in bearing full consequences of my actions. I have seen patient wishes completely disregarded, something I decided to refuse - and therefore got more involved in the administrative side than the clinical side, even if I still do both.

There is a quality problem with some colleagues, one that only financial incentives or legal liability can solve. The US system is far from perfect, but it can give us some inspiration on these points.

I think there's a misunderstanding here. From what you said here:

> As I like to say, this is as good as printing money - I can say precisely what should be changed in a billing statement, why, how much it will gain, and the probability to find matching evidence in the patient file.

I understand that you, or your system, adds items to patients' bills for tests that either have never been performed, or that have been performed unnecessarily.

Is that the case, or does your system check what probably was performed, and makes sure that it wasn't left out of the bill?

> I understand that you, or your system, adds items to patients' bills for tests that either have never been performed, or that have been performed unnecessarily.

The first one would be illegal. You can't bill for things that were not done.

The second one is a matter of interpretation : I do not judge whether it was necessary or not. If it was performed, I try to see how it logically could be argued, using the probability of finding matching evidence, that it was necessary given the case or preexisting conditions - and thus bill for it.

> Is that the case, or does your system check what probably was performed, and makes sure that it wasn't left out of the bill?

The third one, making sure things that were performed were not left out of the bill, is most of the work. The files are incomplete and it requires a probabilistic and interpretative approach, before sending in a human for fact checking.

It's all about providing incentives. The billing rules are complex, but there is some logic in them, and physicians see that too - it change their behaviour. #3 and #2 will directly result in other physicians becoming very careful that everything which should have been performed was - because doing this is highly lucrative, "it is as good as printing money". No need to do anything but following the law and the billing rules.

Truly useless tests won't increase the bill, and therefore they will be weeded out.

I see that as a financial incentive to change behaviours.