L Gordon Moore

“Are health insurance companies generally being fair and honest when they reject claims from policy holders?”

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In Health Care, Number Of Claims Denied Remains A Mystery

Lemme take a crack at this.   Um, I seem to recall some recent posts from colleagues that tell a pretty grim tale regarding rejections.

OK, not all claim rejections are such horror stories.  I had claims rejected because I forgot to fill in a box on the form correctly.  I found the number of the insurer, waited on hold, had to provide a bunch of codes to prove who I was, then the clerk would look up the claim in question and tell me why it was rejected “You didn’t put a modifier on the procedure code.”

“Oh.  What modifier should I have used?”
“We’re not permitted to tell you that.”

That kind of thing is an every day occurrence.  It is why doctors have to hire more and more staff to deal with with the minutia that makes the difference between being paid & not being paid.

The rules change every year.  They are different for each insurer.  They differ for each benefit plan the insurer offers.

“Oh, you have Blue Million with the preferred rider from employer X?  That means you have only a $5 co-pay if this is a sick child visit first visit without a procedure and not on an emergency basis or after hours.”

I asked an insurance guy about what seemed like a systematic delay or denial of payment:

“Oh, we make a lot of money through short term investing of the pool of money we take in before we send it out.  It’s called the ‘float.’  The longer we hold on to the float the more we make.”

All I can think of in reply is how messed up this system is where they do better financially by screwing me.

“The signal to public policymakers is that to attain more health with less health care spending, health plan enrollment must be tilted toward those plans that vigorously reward PCPs and physician groups that excel in low total annual per capita health care spending and clinical outcomes.”

— Ideal Medical Practices (quote from Milstein & Gilbertson Health Affairs article)

“In an important victory for the insurance industry, Senator Max Baucus’s legislative proposal does not call for a government-run health plan that would directly compete with private insurers. Insurance stocks rose on that news Wednesday.”

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Guarded Optimism Among Insurers, but Some Health Sectors Remain Skeptical - NYTimes.com

Somethings about this makes me nervous for doctors, patients, the public, employers……

“Yes, we invent disease, we invent new therapies to treat invented disease…and then we mandate that all people should be forced to pay into this system that’s fundamentally designed to increase costs as much as possible.”

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Tumblr - Jay Parkinson

And a “mwah-hah-hah-hah-haaaa!” to all!

Just picture me standing over you with a big syringe:  “Go ahead.  Make my (pay)day!”

The incentives in health care are so freaking sick!

“I have no self-interest in this fight beyond wanting to wanting to see less tragedy and suffering in the world.”

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Doctors for America - Bringing Doctors Voices to Health Care Reform

Dr. Alice Chen describes her motivation for health care reform.  I share her motivation.  I see a brighter future in which government plays its right and appropriate role regulating the excesses of the insurance industry:

People should not be kicked off their insurance when they become ill.

People should not be denied care because of pre-existing conditions.

Almost every one of us in practice cares for people who have suffered deeply from the status quo.  Patients who cannot afford the multiple co-pays for the meds they need to regulate their chronic conditions.  Patients who have to wait while I jump through administrative hoops to obtain permission from insurance bureaucrats.

We can do better.

“Primary care clinicians routinely face unreasonable time pressures, a chaotic work pace, and bureaucratic impediments. Onerous paperwork requirements that obstruct patient care have to be reduced. And instead of the current system which encourages doctors to rush through as many office visits as possible, physicians who take the time to counsel, guide, and address all of their patients’ concerns should be rewarded. Better valuing the doctor-patient relationship will increase satisfaction, not only for physicians, but for their patients as well.
Such solutions, however, have been largely absent from the health reform conversation.”

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Why the doctor won’t see you now | KevinMD.com

So true, Kevin.

I used to think that I had to have payment reform before I could shift the practice paradigm and start really caring for my patients again, using the full scope of my training in comprehensive primary care.

It finally dawned on me that the paradigm shift started with accepting that I could start myself by putting my own house in order.

1:  Radically reducing practice overhead through useful information technology got me off the hamster wheel.

2:  Aggressive pursuit of comprehensive primary care:

- superb access: patients say “I can get care when and how I need it”

- relationship: superb continuity and the time we need to build trust

- comprehensiveness: learning how to support patients as they navigate the rough waters of complex behavior change

- care coordination: technology and processes in place to bridge the silos of health care

I did this while continuing to work with the insurance industry in my practice, which means that this work came at considerable financial cost to my practice as almost none of this work is valued by the insurance industry.

Because the insurance industry continues to offer only lip service instead of true support for this work, other colleagues of mine have chosen to step out of that paradigm and work directly for patients who recognize the worth of this kind of practice.

I yearn for the day when employers and the gov’t recognize the dramatic reduction in total cost (~30%) that comes from this kind of care.  I yearn for the day when they will unleash the potential of primary care across the US and fully fund our work, but I’m no longer holding my breath.

The paradigm shift may be too radical for insurers, too radical for gov’t programs that are more interested in checking boxes than exploring fundamental change that gets the results they say they want.

The good news is that the patients get it.  They know that this is better for them.  We’ll continue to see docs shift to this new model of practice because it gets them off the hamster wheel, because it makes it possible to practice good medicine again, because it is the right thing to do for their patients.

It bothers me that the cost has to rest on the shoulders of the patients, but right now that’s where we’re finding real support for comprehensive primary care.

Groups like Qliance in Seattle and HealthAccess in Rhode Island and Hello Health in NYC are making this paradigm shift possible for a wider swath of the population and given the intransigence of the insurance industry, that’s where we’re going to see the most interesting advances in care delivery.

Right now primary care physicians have a choice: continue in the current paradigm (“50% of Primary care ready to throw in the towel”) or join the growing community of those who are taking our profession back, re-energized in our work, no longer marking time while waiting for retirement.

“

While the U.S. health care bureaucracy frets and fumbles over what to do, one Anchorage doctor says he has found a way to care for people in a more satisfying, yet cost-effective way. A newspaper advertisement for Dr. Daniel Steward’s office off Dimond Boulevard describes his “Ideal Medical Practice.”

It promises 30- to 60-minute doctor visits, and the ability to make your own appointments online and to communicate via e-mail with the doctor.

”

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Innovative doctor: Anchorage Daily News | adn.com

Hooray Dan!  Another doc not waiting for anyone’s permission or an act of Congress to take matters in his own hands and do what is right for his patients.