Medical Insurance

 

As a benefit to patients, I accept most medical insurance including UHC, Humana, BCBS, Aetna, and Cigna.  I also accept Medicare. This means that I file claims with these companies and that I accept their fee schedules.

 

But I don’t work for the insurance companies, I don’t work for a hospital system, and I don’t work for any institution.  I work only for patients who engage me to help with their medical needs.  I consider it to be a conflict of interests to work for an institution.  I can serve only one master.  Corporate Boards are concerned primarily with profits, and my concern is to provide quality medical care.

 

You may consider your insurance company to be your friend and ally.  This is false.  I consider medical insurance companies to be no better than legalized criminal organizations.  They will collect your insurance premiums, but if you need medical care, often they will make every possible attempt to avoid paying for the care that you need.

 

One of the most onerous strategies used by insurance companies is the requirement for preauthorization for certain tests and services.  This requirement is included in their contracts, but I generally refuse to comply.  The insurance company wishes only to discourage and delay your care, and the requirement interferes with my ability to provide quality care.  It can easily take 30 minutes of my time to educate an insurance company representative about the need for a test or service before receiving approval.

 

How can you trust an insurance representative to know more about your medical needs than an experienced specialist who has talked with you and examined you?  Furthermore, the insurance adjuster is incentivized to delay or deny your needed care.  That’s how his company increases profits.

 

I will not allow an untrained insurance adjuster with an adverse incentive to dictate your treatment.  I will not waste my time communicating with these individuals.

 

The Medicare Advantage (Medicare replacement) policies have been the worst offenders.  For these policies, Medicare pays a fixed amount to the insurance carrier and the carrier assumes responsibility for the medical expenses.  Because the insurance companies can’t increase the amount that they receive from Medicare, profit is increased only by denying or limiting the payments for service.  By replacing regular Medicare with “Medicare Advantage”, patients lose the ability for their physicians to offer care that they have determined you need.  Patients may also sacrifice access to the physician or hospital of their choice.

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Precertification: My Experience

 

I’ve been practicing medicine for a long time: over 50 years.  Precertification didn’t always exist.  But neither did insurance companies.

 

Precertification is a process by which a patient’s insurance company requires that the treating physician contact the insurance carrier and explain the reason for the desired test or procedure.  The insurance carrier then has the authority to approve or deny payment for the requested service.

 

The stated goal of precertification was to avoid unnecessary or inappropriate tests and procedures.  This was always a lie.  The goal of precertification has always been to improve profits for the insurance industry.

 

In the early days, insurance carriers usually accepted the requests.  Over the years, denials have become more aggressive and even consistent.  Additionally, the list of tests and procedures requiring precertification has greatly expanded.

 

 

Here is my experience with precertification:

1. The physician determines that a patient needs a procedure that is on the precertification list for their insurance company, perhaps a CAT scan.

2. A staff member employed by the physician attempts to pre-certify the test by communicating with a relatively untrained employee of the insurance carrier.  This staff member probably has a list of diagnoses or situations that are approvable, but there is also an expectation that the insurance staff will initially deny a percentage of requests.  A straightforward request based on the insurance carrier algorithm might be approved by the insurance staff.

3. The physician’s office will generally object to a denial.  At this time the physician will be required to talk directly with the relatively untrained insurance carrier employee.

4. The insurance employee will ask the physician a series of routine questions.  The insurance staff already has answers to these questions, so the intention and result is to discourage the physician by wasting as much time as possible.

5. After answering all questions, the physician is placed on “hold” while a nurse working for the insurance company comes on the line.  The nurse asks the same questions and gets the same answers wasting more physician time.

6. Next, the busy physician is referred to a physician who works for the insurance company.  This is usually an older physician who has no real understanding of the specialized medical field and no real understanding of the patient’s needs.

7. After a comprehensive explanation to the insurance company physician, the requested test or procedure is almost always approved.  I have never had a requested test or procedure not eventually approved, but my wasted time can easily be 30 minutes for a single approval.  The obvious intent is to discourage me from ordering needed tests and procedures.  Precertification can easily take more time than patient care, and I am paid nothing for this time.

 

I enjoy evaluating and treating patients, but I hate wasting time on administrative nonsense.  I do not have a team or employee dedicated to precertification.

This is what I will do:

• I will evaluate you and recommend whatever tests that I consider to be needed.

• I will not negotiate with your insurance company to pre-certify tests.

• I will provide complete records that explain what I advise and why the tests are needed.

• Your primary care provider can pre-certify and order the needed tests after which I can see you to discuss the results.  Almost all PCPs are employed by an institution that can provide these tests and that profits from these tests.  These institutions have dedicated employees who pre-certify tests.

• If you have no other option, I can pre-certify needed tests, but I will charge a minimum of $200 for my time and inconvenience.  Your insurance carrier will not pay for this service, so this will be a cash expense for you.

 

 

What is the solution to this problem?

• Physicians could refuse insurance company contracts that require precertification.  This would be effective only if a high majority of physicians participated.

• Because large healthcare institutions currently employ most physicians, the institutions could decline contracts that require precertification.  As these institutions consolidate, increasing their market power, this is a realistic possibility.

• Legislation could make precertification contracts illegal.  Although an option, this seems unlikely.  Elected officials are corrupted by large contributions from the insurance industry.  Beyond that, increased regulation has consistently harmed physician productivity rather than improving patient care.

• Physicians could simply refuse to accept any insurance contract.  Although challenging, this is a realistic option.  As the shortage of medical and surgical specialists worsens, patients will have no realistic alternative to seeking care from whatever physician is available.  Once again, our government is an enemy of the people in this situation.  The federal requirement for having health insurance under threat of a penalty means that patients would be paying twice for care were they to see an out-of-network physician.  The government is subsidizing a corrupt insurance industry by this requirement.