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medpundit |
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Saturday, October 05, 2002-A patient is seen and treated in the office. The doctor submits the bill to the insurance company, which, according to the contract it has with the doctor, is supposed to pay the bill within a certain number of days, say 30. On the thirtieth day the doctor doesn’t get a payment. Instead he gets a form from the insurance company claiming they need more information about the visit. Was it for a pre-existing a condition? To make it even more difficult, the letter doesn’t specify which diagnosis for that visit it has concerns about, and sometimes it doesn’t even state the day of service. So, if a patient saw the doctor for two things - say an ear infection and to have his blood pressure medicine renewed, or if he’s been to the office twice for two separate problems, the doctor’s staff has to call to clarify things, a process which can take minutes to days. Then, the form has to be mailed back to the insurance company. They won’t accept the information by phone. This happens even if the condition is clearly not a pre-existing one. In fact, I see it most frequently for office visits that have been for an acute problem such as an ankle sprain or an ear infection. The only reason the insurance company has for doing this is to delay payment by another couple of months. -A patient is admitted to the hospital for chest pain. Tests show that he has severe coronary artery disease and needs coronary by-pass surgery. He needs surgery urgently, but not emergently. The next day is Sunday, a day when the operating room is only staffed adequately for emergencies. (With the cut in payments, the hospitals can’t afford full staff on Sundays) Or perhpas it’s the middle of the week, but all the surgical suites are booked for the next day, or there are more emergency cases than expected and the patient’s surgery gets delayed a day. The patient is stable enough to wait in the ICU on intravenous blood thinners, but not stable enough to go home for a day. The delay isn’t because his doctors are lazy or because the hospital wants to crank out an extra day of insurance money, but because it wouldn’t be safe to stretch the resources of the operating rooms and staff to cram him into the schedule. The insurance company refuses to pay for the day he spent in the hospital on intravenous blood thinners because it wasn’t “medically necessary.” They do the same thing with other surgeries, too, that are needed urgently, but not emergently. They refuse to acknowledge the limitations of resources and manpower, and the nature of some diseases and their appropriate treatment. - A doctor belongs to an HMO. Every so often, he’s supposed to get a check for his capitation payments - the amount of money the insurance company has agreed to pay him for each patient who signed up with him. The check doesn’t come. He calls the HMO and gets shuffled from department to department without ever getting satisfaction. The check finally comes two months late, but lower than the doctor expected. He suspects he has more patients with that plan than the insurance company is giving him credit for. He asks the insurance company to give him regular updated reports that tell him how many patients he has with that plan. The insurance company, somehow, never gets around to it. Ross is skeptical that 600,000 physicians could have the same grievances against the companies. I’m skeptical, too. I don’t think there are 600,000 doctors signed up for the class action suits. (In 1999 there were only a little less than 800,000 physicians in the country.) There’s no reason to think that the insurance companies are singling out certain doctors to delay payment. These sorts of tactics are their standard way of doing business. What they do to one of us, they do to all of us across the board, so a class-action lawsuit is certainly a legitimate approach. As to the consequences as far as insurance company’s bottom line - so what? Their ruin could be the saving of our healthcare system. They aren’t in the business for humanitarian reasons, or because they have some divine mission to lower healthcare costs. They only serve as middle men who inflate the cost of basic healthcare, especially when it comes to primary care. A substantial amount of the overhead of a physician’s office goes to paying staff to submit bills to and try to collect from the insurance companies. Doctors who have quit accepting insurance payments and charge their patients directly at the time of service report that doing so let’s them cut their fees by 30% to 50%. Liberal insurance coverage that completely shields the patient from the cost of their care also fosters indiscriminate use of medical testing and drugs. When patients have to shoulder some of that financial burden, they’re more willing to take the prudent approach to testing and to accept generic drugs over brand names. The majority of doctors never welcomed managed care. We just had no choice as more and more employers moved to the system in the 1980’s and 1990’s. Health insurance needs to return to what it once was - insurance for catastrophic medical bills, not insurance for run-of-the-mill doctor’s visits and minor illnesses. posted by Sydney on 10/05/2002 09:05:00 AM 0 comments 0 Comments: |
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