In Corporate Hands, Health Care Bureaucracy Blooms

By David S. Hilzenrath
Washington Post Staff Writer
Tuesday, September 20, 1994; 7:10 PM

A market-driven revolution in American health care is giving private insurance bureaucracies more influence over day-to-day medical decisions than President Clinton ever proposed giving the federal government.

For a glimpse, enter the Rockville offices of Mid Atlantic Medical Services Inc., the Washington area's largest managed-care company, where dozens of employees wearing telephone headsets occupy rows of cubicles.

Their job is to second-guess physicians; doctors and medical executives call them the "health police."

Utilization Management Nurse Coordinator Diane Erickson quizzes surgery candidates on their symptoms and feeds the answers into a computer, which is programmed to judge whether Mid Atlantic should pay for their operations.

"Are you able to do light housekeeping?" Erickson asks an arthritic 54-year-old woman seeking a hip replacement. "Are you able to climb stairs?"

"Does the pain ... wake you from sleep?"

At a rate of 142 calls a day, Senior Provider Relations Representative Paul Gebhardt fields questions from doctors trying to comply with Mid Atlantic's billing and referral procedures. A Rockville physician's office wants to know why the company rejected the bill for a chest X-ray taken at Shady Grove Hospital.

"Did the doctor get a pre-certification from the Utilization Department before sending the member to the hospital for that service?" Gebhardt asks. "We'd need a pre-certification for that service to be done at the hospital and be covered."

Some workers prepare statistical profiles of the doctors in Mid Atlantic's networks, enabling them to tell a particular dermatologist that charges for his patients are running 42 percent above the average set by the rest of Mid Atlantic's dermatologists.

Other employees administer a computer program to detect billing subterfuges by physicians.

The bureaucracy extends beyond the five office buildings that make up Mid Atlantic's headquarters, into the wards of area hospitals, where company nurses review patients' charts and prod doctors to discharge members of Mid Atlantic's MD-IPA and Optimum Choice health maintenance organizations as soon as possible.

Opponents of broad national health care legislation have argued that proposals by Clinton, Senate Majority Leader George Mitchell (D-Maine), House Majority Leader Richard A. Gephardt (D-Mo.) and others would create an intrusive government health care bureaucracy.

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