small microscope

Insurance - trials and tribulations

As a child, I recall our family physician making house calls when I had a variety of medical ails to include mumps and measles. My parents paid Dr. Shoemaker, now long gone, a fair fee for his gallant and heartfelt efforts to nurse us back to health. He was kind, he cared and he was part of the family.

Somewhere along the way, insurance inserted its ugly head between patient and doctor corrupting centuries old bonds of trust and compassion that forged that now often fragile relationship.

Originally promised as a mechanism to ensure doctors were paid without worries and patients received necessary care, insurance in its various forms has instead become more complex, convoluted, and in direct contrast to their purported and presumed purpose with the end goal seemingly aimed to enrich the insurance company or the mega institution at the expense of patient care and the private practitioners.

While saying health insurance is complex and convoluted and merely reflective of many processes in modern life may be comforting and are, in my opinion, idealistically simplistic, it would do a vast disservice in explaining what is truly transpiring in this industry.

In broad terms, the health insurance industry's only method to make their record making profits is based on not paying their customers (the patient population it presumably serves) or their providers. Anyone who has interfaced with insurance companies, whether patient or provider, recognizes that the roadblocks placed in the system are intentionally strewn along the road to reimbursement to promote attrition leading to diminished provider payment and increased profit margins for the insurance companies.

Providing excellent care to complex medical cases was our mission when creating our current practice. However, an acute awareness of poor reimbursement for complex care, and an inability to afford billing personnel to engage insurance companies in endless battles for payment of services already rendered, led to our decision a number of years ago to create an alternative model for comprehensive, complex care utilizing technology, whenever possible and appropriate, for the consultation and management of patients. Although we recognize our practice model may not work for everyone we elected a number of years ago to practice medicine the way we believe it should be practiced.  In our opinion, our model allows us to devote the necessary time to the complex thought processes and extraordinary workload that comes with diagnosing and managing complicated patients. Nonetheless, even in our model, we are forced to interact with insurance companies to assist patients as best we can with the limited amount of time we have to improve reimbursement for various services or prescriptions. Roughly 60% of Mike's time and 30% of Dr Kendall's time is spent on insurance matters and we do not even accept insurance!

Along the way, we have encountered numerous outrages and out right unethical maneuvering by insurance companies to deny patient services. Several of the most egregious examples are outlined as follows:

  • An insurance rejection letter was sent that listed the patient, their date of birth, date of our service, the CPT codes we used, and our charges. The reason for the rejection? No such claim was filed. Mike called and asked when the insurance companies had begun the practice of hiring telepathics. No answer was provided.
  • Insurance rejected a claim for a patient because it was not printed in red ink. 
  • Prior to a NEW patient appointment insurance demanded provision of diagnosis codes and medical records. What were we thinking? We had always thought we had to have an appointment before assigning a diagnosis or generating medical records.
  • An insurance letter was MAILED to us demanding we provide our address. 1) didn't they already have the address in order to mail their demand letter? 2) Why did the Federal government demand that all providers have an NPI number (National Provider Identification which they must register their contact details along with their specialty and other details) if no one uses it?
  • In-Network request rejected because a local provider was found….. 1,237 miles away from the patient!
  • Testing rejected because it is not medical necessary, as determined by a Medical Director boarded in gynecology!
  • Flatly rejecting genetic services, counseling or testing stating that genetics is not covered per your policy. They often forget to read further or ignore the section of majority of policies that further state these genetic services are covered when they are related to the “prevention, diagnosis, or treatment of an illness; the information will affect the course of treatment for the plan member; the care and/or treatment is likely to improve outcome; this improvement is attainable outside the investigational setting”. Moral of the story, do not take their word for it - demand to see the full section of your plan that they are referencing. 
  • Denying in-network approval because another in-network provider exists – who refers their patients to us! In another case, a patient was referred to a provider who was no longer practicing medicine. Another provider told the patient they have never seen a mitochondrial patient.
  • Insurance refused faxed information from a patient claiming a phone call from the provider was necessary.  During the requested phone call the insurance representative demanded the information be faxed meaning the initial steps were all that was necessary wasting precious time and energy from all parties involved.
  • “Approval is not a guarantee of payment.” Insurance companies will pre-approve services and laboratory testing only to deny payment 6 to 9 months later for services ALREADY provided.
  • Demanding Prior Approvals for prescriptions. Prescriptions written by licensed and boarded physicians are now requiring prior approval by unqualified reviewers leading to inability of many patients to gain access to necessary medication.  This has exponentially worsened since January 2012.
  • Demanding a Peer Review with an unqualified reviewer in direct conflict to many state statues including the Georgia State statue O.C.G.A. 33‐20 A‐5 (3) (B) (ii)that states in part:Such hearing shall be conducted by a panel of not less than three persons, at least one member of which shall be a physician other than the medical director of the plan and at least one member of which shall be a health care provider competent by reason of training and licensure in the treatment or procedure which has been denied.

Certainly, these are examples of extreme obstructionary behavior on behalf of insurance companies to prevent coverage and care.  While a complete overhaul of the system may be required to eliminate this type of egregious behavior long term, there are many things that we as a medical and patient community can do now to deal with the existing healthcare system.

Among the most powerful tools that a family or patient can utilize is requesting a care manager through their insurance company.  Patients have relayed incredible stories of how a case manager cut through all of the bureaucracy to assist in care provision. This person is, by definition, an advocate for you in your insurance system helping you navigate its complexities to provide you with the best care.  They wear two hats, one of the insurance company when interfacing with you and the other when interfacing within the insurance company on your behalf. Keep in mind that some case managers may work more effectively with certain individuals so if you find that your relationship with your case manager is not productive, you can request a new representative.

Due to changes in the healthcare system, many individuals, rather than employers, must now seek out and select their own insurance carriers creating more educated and savvy consumers.  As such, patients have gained a more powerful voice in the healthcare industry and can begin to condemn elicit practices by utilizing the power of their pocketbook to select more ethical insurance providers. If one insurance carrier earns a very bad reputation for their policies, boycotting them will lead to a reversal or change in their practices.

When reason and all else fails, we recommend that patients contact their state insurance commissioner to file a complaint. When that fails, elected officials may be of help. Providers hold little sway but voters are far more powerful. Pressure placed on insurance companies from state insurance commissioners or elected officials may lead to changes in policy and practice if enough people take the time to report the problems. No one else can hold insurance companies accountable.

In summary,insurance was initially implemented to improve access to payment for healthcare. However, since its implementation, many practices on behalf of insurers has led to anything but leaving the system fraught with problems and few solutions. In my opinion, long term change will require an overhaul of the existing insurance system by addressing the real issues at hand (for another Factoid Friday). Nonetheless, in the meantime, both providers and patients must utilize what exists.   Obtaining a case manager, using your powerful voice and financial pressure to help mold insurance practices and contacting insurance commissioners to hold carriers accountable can go a long way to alleviate some of the day-to-day problems mito families and others with chronic disease must face in the US healthcare system.


Fran Kendall, M.D.

This post is not meant to be a recommendation or a substitute for professional advice and services rendered by qualified doctors, allied medical personnel, and other professional services. The responsibility for any use of this information, or for proper medical treatment, rests with you.