It doesn’t seem like too much to ask for a doctor to know what each patient’s insurance will cover and at what rate. In the single-payer system where I live, not only does the doctor know, but so does anybody who may interested. There’s no deep mystery about fees which insurance companies have turned into some kind of mysterious black art – the exact fees are all in a document called “Schedule of Benefits, Physician Services Under the Health Insurance Act, Ontario Ministry of Health and Long Term Care”. And it’s of course the same for every patient, and everyone is covered unconditionally, so there’s no question or hassle about getting paid.
These are the pertinent responsibilities:
What the doctor or hospital must do: Enter the appropriate code(s) in the OHIP online billing system. What the patient must do: Show their health card. After that, nothing. Literally, nothing.
Doctor gets paid automatically in the next billing cycle.
If it sounds simple and streamlined, it is. This is what happens when you take useless parasitic insurance companies out of the system.
The clinic I use for health care has a patients advocate and an insurance person (s) employed. The Doctor doesn’t usually get involved with that. Altho’ I see a P.A. on normal visits and she will get into insurance questions with me. I have a long history of asthma and a family history of breast cancer. She makes sure I do all the yearly tests that my insurance covers 100%. I appreciate her, to no end. I realize this is not the norm. But it easily could be
No, with all respect, it couldn’t be the norm. The essence of any insurance business model is to discourage claims by requiring deductibles or co-pays or some other form of monetary disincentive and cost reduction strategy, as well as (usually) payment limits, and secondly to adjudicate each and every claim with a view to improving the bottom line by either (in the case of health insurance) requiring less expensive treatment protocols or, if legally possible, denying the claim altogether. The lack of a uniform coordinate fee structure and the lack of centralized cost control also means costs will continue to spiral out of control and, as noted, no one will ever really know what they are or know for sure that they’re even going to get paid.
I’m glad to hear that you’re getting your tests covered in full but this sounds more like a case of your health interests and the insurance company’s cost-saving interests being aligned in that preventive medicine and early detection saves them money. It’s not because they care about your health.
American’s are raised to be self-reliant in theory, but not in practice. Therefore, each of us think whenever s/he needs help help, s/he deserves it, but the Other Person just needs to be taught to fish. In my experience, we are amazingly ignorant, not venal.
Now that this awful system has finally begun to annoy and inconvenience the providers as well as the patients, I don’t understand why the professional medical associations don’t band together and get their lobbyists to lean on congress for change, if they truly don’t like the system as it is. They are the ones with some actual clout. We patients have zilch in the way of clout.
In another thread, one of the right-wing idiots (Hi, Starving Artist !) praised health insurance companies which return 97% of their premiums as health benefits. I asked him if he had to subtract the salaries of 2.6 million (with an M) employees of insurance companies from premiums in order to come up with this stat. He replied, in effect, that these employees were productive members of society who I wanted to put on the unemployment rolls, that their denying of care was essential to insurer profitability. And that, yes, he was too stupid to realize insurer expenses like salaries were not included in “profit.”
If insurance companies are barely able to turn a profit under Obamacare, someone forgot to tell the Job Creators who invest in insurer stocks. It’s true that Anthem shares have multiplied by only 4.5x over the last seven years — they haven’t even quintupled :o — but shares of Cigna and Aetna have each sextupled over the same period, and the biggest insurer of all, UnitedHealth Group has septupled in value.
That’s sextupled and septupled, each with an S. No wonder the Republicans, party of rich stockholders, have been loathe to fully vent their spite against ACA.
But to do anything else would be socialism, and the US is only in favour of collective funding of national services when it comes to military spending.
Let me add a little clarification. I’ll give an example of what would be a similar situation. Assume I have a patient that is a premenopausal woman.If the initial blood test was a screening blood count, for example, it would have shown the patient to be anemic, enough to cause symptoms. I would have added on an iron test to the original sample to see if she needed iron. This test was normal. I then would have told this hypothetical patient that since she was completely asymptomatic I would recommend watching for problems and repeating the blood count in 2-3 weeks rather than doing extensive further testing, She came in to repeat the blood count and it showed mild anemia and she was informed that I would recommend monitoring the labs. It was only the equivalent of this second blood count that was denied.
Since I order over a hundred tests on at least 10-15 patients daily, and reviewing an insurance plan to see if each and every test is covered would take hours, and I participate in hundreds off plans, it is not feasible to check the patient’ Insurance each and every time. I obviously know the basics, which labs take which common insrances etc but when I get one of the less common ones I sometimes ask the patient to check. If a patient has a high deductible plan, I have a list of labs and prices and can direct them to the least expensive but the patient usually knows that they have a high deductible and lets me know as soon as i tell them they need tests. I have never had a plan that would not pay for a repeat blood count for anemia unless it fell under the patient’s deductible.
As far as how I handle billing, let me just say that I have been burned too many times to count.
Billing solution #1- I hired a full time biller with 20+ years of experience and good references. She made a good salary but the money wasn’t coming in. I had a computer system for scheduling but did manual billing. When I checked on her she seemed to be ignoring the rejected bills. At the end of the year, there was $5000 in cash unaccounted for. My receptionist saw her down at the local bar selling viagra pills. I fired her which meant she left her mess of billing behind.
Billing solution #2-I vowed never to leave one person in charge of the billing again and hired a billing company used by several local practices. Because in primary care we bill smaller amounts for more visits (rather than one big amount for global surgical care) the billing is more work and therefore more expensive. I paid about 8% of gross collections to them. They did the billing and sent reports and while the account receivables were better and I got monthly reports, there were two company cofounders and the one we worked with left the company and moved to another state. This was when the government was pushing for electronic medical records and I wanted to put one in. He was pushing for a system he had a deal with. I investigated and found 5 plans that met government standards for meaningful use and his was not one of them. He was not happy about working with another plan. I eventually chose a plan that actually integrated the billing with the EMR and the entire deal was less than I was previously paying. However, while they could import demographic data and scheduling they insisted on starting billing clean. I struck a deal with the billing company to continue to clean up accounts receivable for 6 months for a portion of collections. It later turned out that his notion of cleaning up accounts receivable was to bill the patient If the insurance didn’t pay and If the patient didn’t pay he simply sent them the same bill every month without doing any further investigation. The 6 months passed and I again wrote off thousands of dollars.
Billing solution #3- I have an integrated medical record and billing system. They automatically kick back bills that are not “clean” and I can fix them right away. They check on denied claims and call the insurance to try to fix them before sending them back to us. My staff can deal with some of the easier stuff, like name changes and requests for more information but I insist on seeing all other denials personally. I can run my own detailed reports whenever I want. It is not perfect but it is much better than anything else I’ve done. That said, there are always problems, like if a Medicare patient switches to an HMO that we don’t participate with and when we double check at each visit for insurance changes tells us that they are still on Medicare without understanding that the HMO is different. In these cases, we are not their primary provider ( Medicare just assigns one if the patient doesn’t choose) and Medicare does not pay us but Medicare rules forbid billing patients for covered services and even uncovered services require a signed form beforehand. In these cases, the only solution is for the doctor to call to get a one-time exemption until the patient can change back to the regular Medicare they thought they still had. ( I posted on another thread about dealing with a Medicare PPO that is refusing to pay earlier this week)
Tl:dr I have been burned in the past and now oversee my billing personally much more closely.
Let me add a little clarification. I’ll give an example of what would be a similar situation. Assume I have a patient that is a premenopausal woman.If the initial blood test was a screening blood count, for example, it would have shown the patient to be anemic, enough to cause symptoms. I would have added on an iron test to the original sample to see if she needed iron. This test was normal. I then would have told this hypothetical patient that since she was completely asymptomatic I would recommend watching for problems and repeating the blood count in 2-3 weeks rather than doing extensive further testing, She came in to repeat the blood count and it showed mild anemia and she was informed that I would recommend monitoring the labs. It was only the equivalent of this second blood count that was denied.
Since I order over a hundred tests on at least 10-15 patients daily, and reviewing an insurance plan to see if each and every test is covered would take hours, and I participate in hundreds off plans, it is not feasible to check the patient’ Insurance each and every time. I obviously know the basics, which labs take which common insrances etc but when I get one of the less common ones I sometimes ask the patient to check. If a patient has a high deductible plan, I have a list of labs and prices and can direct them to the least expensive but the patient usually knows that they have a high deductible and lets me know as soon as i tell them they need tests. I have never had a plan that would not pay for a repeat blood count for anemia unless it fell under the patient’s deductible.
As far as how I handle billing, let me just say that I have been burned too many times to count.
Billing solution #1- I hired a full time biller with 20+ years of experience and good references. She made a good salary but the money wasn’t coming in. I had a computer system for scheduling but did manual billing. When I checked on her she seemed to be ignoring the rejected bills. At the end of the year, there was $5000 in cash unaccounted for. My receptionist saw her down at the local bar selling viagra pills. I fired her which meant she left her mess of billing behind.
Billing solution #2-I vowed never to leave one person in charge of the billing again and hired a billing company used by several local practices. Because in primary care we bill smaller amounts for more visits (rather than one big amount for global surgical care) the billing is more work and therefore more expensive. I paid about 8% of gross collections to them. They did the billing and sent reports and while the account receivables were better and I got monthly reports, there were two company cofounders and the one we worked with left the company and moved to another state. This was when the government was pushing for electronic medical records and I wanted to put one in. He was pushing for a system he had a deal with. I investigated and found 5 plans that met government standards for meaningful use and his was not one of them. He was not happy about working with another plan. I eventually chose a plan that actually integrated the billing with the EMR and the entire deal was less than I was previously paying. However, while they could import demographic data and scheduling they insisted on starting billing clean. I struck a deal with the billing company to continue to clean up accounts receivable for 6 months for a portion of collections. It later turned out that his notion of cleaning up accounts receivable was to bill the patient If the insurance didn’t pay and If the patient didn’t pay he simply sent them the same bill every month without doing any further investigation. The 6 months passed and I again wrote off thousands of dollars.
Billing solution #3- I have an integrated medical record and billing system. They automatically kick back bills that are not “clean” and I can fix them right away. They check on denied claims and call the insurance to try to fix them before sending them back to us. My staff can deal with some of the easier stuff, like name changes and requests for more information but I insist on seeing all other denials personally. I can run my own detailed reports whenever I want. It is not perfect but it is much better than anything else I’ve done. That said, there are always problems, like if a Medicare patient switches to an HMO that we don’t participate with and when we double check at each visit for insurance changes tells us that they are still on Medicare without understanding that the HMO is different. In these cases, we are not their primary provider ( Medicare just assigns one if the patient doesn’t choose) and Medicare does not pay us but Medicare rules forbid billing patients for covered services and even uncovered services require a signed form beforehand. In these cases, the only solution is for the doctor to call to get a one-time exemption until the patient can change back to the regular Medicare they thought they still had. ( I posted on another thread about dealing with a Medicare PPO that is refusing to pay earlier this week)
Tl:dr I have been burned in the past and now oversee my billing personally much more closely. I think single payer would be the best solution. I have no problem with a two tier system as long as there is a basic health plan for all free of charge financed by taxes.
We seem, in England, to be getting multiple politicians making comments about moving towards a ‘More American healthcare system’. Threads like this make me want to leave bags of flaming dog poop on their doortsteps.
:smack: I read the first of his two almost identical and rather long posts, then skipped the 2nd, where the major (or only?) change was to … answer my question! Sorry, psychobunny.
The political class has always been keen for the public purse to pick up the pieces of deregulation - in other words when investors have made their money and bought legal exemption in DC for the inevitable consequences; bailing out Wall Street variously, picking up the pieces of the opiads crisis, environmental damage, etc, etc.
There are employer based health plans where the insurance actually does care about the patients outcomes, well being, and happiness with the services.
The employers pay alot of money to the insurance company to make sure that their workforce is healthy and productive, and actually has negotiating power, in that, if the insurance company is not keeping their workforce happy and healthy, they will change to a company that will.
These used to be more common, I’ve had a couple employers well in the past that had such generous plans. They are certainly less common now, but I doubt they are entirely gone.
I wonder how many people THINK their insurance if fine because nothing horrible has happened to them yet? here’s the thing, people are forced into bankruptcy despite having health “insurance” and that shouldn’t be possible.
I find it hard to associate the idea of “caring” with a profit-making corporation that is simply fulfilling its contractual obligations, and perhaps doing it better than average but only under threat of losing a major corporate contract, from what you just said. Maybe their ethical standards were higher than average, I don’t know. But caring doesn’t consist in meeting your legal contractual obligations, it consists in going above and beyond. The trouble with most insurers, aside from all the structural nightmares intrinsic to the mercenary insurance approach to health care, is that they fail to meet ethical and moral obligations by finding creative ways to escape contractual obligations. I’d be impressed if they extended you major coverage that they didn’t have to.
I don’t claim that a public single-payer system “cares” in some human sense any more than a private health insurer, but there are two huge differences. One, the system is set up fundamentally to serve the public interest and not the stockholder interest. Two, and most important of all, whether they “care” or not is irrelevant because structurally they’re out of the picture; it is intrinsic to single-payer that health decisions are relegated to the doctors and their patients, where they belong. And most doctors, in my experience, do genuinely care about their patients.
And that is really the crux of the matter. The most that a “caring” insurance company can do is pay your bills. The alternative is their power to deny coverage and deny you health care. It’s the doctors who actually provide care. In single-payer, they are entrusted with that responsibility with a minimum of interference.
Actually, there is much that the federal government does that is “socialist” in nature, from universal mandatory public education, government owned or subsidized utilities, public health and science research funded by federal revenues, to most public roads that are funded by general revenues at the federal, state, and local level rather than through investment vehicles such as bond issues. The government pays for these things because they are a general benefit to all, and improve the nation in terms of competitiveness, productivity, and general gross domestic product, as well as giving the nation reign to lead the world in how we think things should be done (for better or worse) than following someone else like China or Russia.
The purpose of government is to do those things that commercial entities and joint ventures of private capital cannot or will not do on their own, either through lack of return on investment or the prohibitive sheer capital reqiurements. The Global Positioning System which is now a many-multi-billion dollar industry that is used casually by many drivers and virtually any business that requires geographic information is ‘socialist’ insofar as being a former strategic asset for which access was gifted to anyone with a receiver. The NASA space program is ‘socialist’ in terms of the benefits it has provided to the public at large (telecommunications, weather surveillance, basic science) and arguably an entitlement for small and large corporations which have received massive contracts on the public teat. Rural electrification, public waterways and reservoirs, US and Interstate highways are all ‘socialist’ and all have benefited the nation as a whole such that we aren’t one of those “shithole countries” where fat kleptocrats lord over illiterate starving peasants that nobody wants.
Whether you regard basic health care as some kind of ‘human right’, it is demonstrably in the public interest that people are healthy, and the physically and mentally ill receive attention and treatment so they are not sprawled out on the sidewalk in one of the bankrupt, ‘failing’ cities that looks all to much like one of those “shithole countries” that it is so easy to disdain from a position of wealth. Whether a ‘single payer’ system is the best solution or not (I’m not pursuaded that this alone will do much to fix our otherwise for-profit health system without imposing further controls on cost), ensuring that everyone has access to basic medical care without having to go to the emergency room and then dodge bill collectors, or go into bankruptcy to pay for common procedures or treatments that are an order of magnitude more expensive in this country than they are anywhere else should be the priority of any legislator or political executive who wants to make even vague noises about compassion or improving the competitiveness of the nation.
