Insurance companies manipulate the doctor-patient relationship for financial gain


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I am pediatrician who has been practicing for almost twenty years. During my career, I have been employed by two different free-standing children’s hospitals, a non-profit community-based health center, and now I own my own practice. In every setting, I have had to generate coding and billing for my work even when my salary was independent of that billing.

There is no other profession that would dutifully learn the “rules” of coding knowing that the fee charged does not reflect the work involved and the reimbursement provided is not at the discretion of the person benefiting from the service. This idiocy is the lava that bubbles under the surface of each patient interaction. Most days my staff receives the spewing ash from insurance companies, but sometimes we all get burned.

For example, about a month ago I diagnosed a teen patient of mine with “adjustment disorder with anxiety,” a fairly common diagnosis in adolescents. Today the insurer denied my claim because I am not in their network for mental health providers. My options were to bill the family for the entire visit or resubmit the claim with additional information and a new code.

My office staff decided to try and resubmit the claim rather than bill the family. They asked me if I thought a different code might be more accurate. Since primary care doctors treat a variety of problems in their patients including mental health, multiple problems might be discussed at any one encounter.

Furthermore, for each of these problems, there are at least a few different codes that apply. Physicians quickly and easily determine which of these options to choose. We also use set coding rules to help us figure out if we have done enough work to justify billing for each of the problems discussed. I guess I picked the wrong code. Even with an approved code, the insurance reimbursement for 50 minutes talking with a teenager was going to be less than freezing a few warts.

I contemplated calling this insurance company to ask if they expected me to sign an additional contract, so I can bill for a mental health diagnosis. But who at the insurance company would talk to me? It would not be someone who could answer that question. I could report the insurer to the local state insurance commission, but that takes more work than refiling the claim and choosing an alternate code next time.

Doctors need to stop sticking ourselves with the red tape created by insurance companies. Now that we have electronic records, let’s finally put them to good use. We can give a copy of each office visit to our patients and have them send it to the insurance company for reimbursement. That is how it worked when I went to the doctor as a child. Back then we mailed claims. Insurance companies could use fax machines or create secure patient portals to receive claims directly from their members. Doctors could then collect payment for their very transparent fees at the time of the visit. I think patients would love it. Most of them have high deductible plans, and although I can tell them what my fees are, I can never tell them what they will actually have to pay because only the insurers can work that magic. I would accept bundled payment for well care and vaccinations, but they would need to tell me their reimbursement schedule each year, so I could be sure my patients would be reimbursed the full amount.

With the current system, the insurance company manipulates the doctor-patient relationship for financial gain. They know that doctors will choose to provide free care sometimes or eat the cost of a visit to spare their patients the expense of some made up rule like your doctor is in-network for pneumonia but out of network for depression. They know we will be sure to complete all the additional paperwork they demand for expensive drugs or imaging.

We think our extra work is helping our patients, but in the big picture, they are paying a greater cost. Our system will not change until every doctor realizes that coding and billing are a violation of our Hippocratic oath. Every primary care doctor: pediatrician, internist, family practitioner, and gynecologist must stop coding and filing insurance claims. Imagine if we all did this tomorrow. Would we even know what our fees would be? If CVS can purchase Aetna, I’m sure we can organize to stop choking ourselves on their red tape. Otherwise, in fifty years the only doctors who will be able to be transparent about fees will be working for CVS.

Denise A. Somsak is a pediatrician.

Image credit: Shutterstock.com


2K Shares

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Your email address will not be published. Required fields are marked *

Insurance companies manipulate the doctor-patient relationship for financial gain


2K Shares

I am pediatrician who has been practicing for almost twenty years. During my career, I have been employed by two different free-standing children’s hospitals, a non-profit community-based health center, and now I own my own practice. In every setting, I have had to generate coding and billing for my work even when my salary was independent of that billing.

There is no other profession that would dutifully learn the “rules” of coding knowing that the fee charged does not reflect the work involved and the reimbursement provided is not at the discretion of the person benefiting from the service. This idiocy is the lava that bubbles under the surface of each patient interaction. Most days my staff receives the spewing ash from insurance companies, but sometimes we all get burned.

For example, about a month ago I diagnosed a teen patient of mine with “adjustment disorder with anxiety,” a fairly common diagnosis in adolescents. Today the insurer denied my claim because I am not in their network for mental health providers. My options were to bill the family for the entire visit or resubmit the claim with additional information and a new code.

My office staff decided to try and resubmit the claim rather than bill the family. They asked me if I thought a different code might be more accurate. Since primary care doctors treat a variety of problems in their patients including mental health, multiple problems might be discussed at any one encounter.

Furthermore, for each of these problems, there are at least a few different codes that apply. Physicians quickly and easily determine which of these options to choose. We also use set coding rules to help us figure out if we have done enough work to justify billing for each of the problems discussed. I guess I picked the wrong code. Even with an approved code, the insurance reimbursement for 50 minutes talking with a teenager was going to be less than freezing a few warts.

I contemplated calling this insurance company to ask if they expected me to sign an additional contract, so I can bill for a mental health diagnosis. But who at the insurance company would talk to me? It would not be someone who could answer that question. I could report the insurer to the local state insurance commission, but that takes more work than refiling the claim and choosing an alternate code next time.

Doctors need to stop sticking ourselves with the red tape created by insurance companies. Now that we have electronic records, let’s finally put them to good use. We can give a copy of each office visit to our patients and have them send it to the insurance company for reimbursement. That is how it worked when I went to the doctor as a child. Back then we mailed claims. Insurance companies could use fax machines or create secure patient portals to receive claims directly from their members. Doctors could then collect payment for their very transparent fees at the time of the visit. I think patients would love it. Most of them have high deductible plans, and although I can tell them what my fees are, I can never tell them what they will actually have to pay because only the insurers can work that magic. I would accept bundled payment for well care and vaccinations, but they would need to tell me their reimbursement schedule each year, so I could be sure my patients would be reimbursed the full amount.

With the current system, the insurance company manipulates the doctor-patient relationship for financial gain. They know that doctors will choose to provide free care sometimes or eat the cost of a visit to spare their patients the expense of some made up rule like your doctor is in-network for pneumonia but out of network for depression. They know we will be sure to complete all the additional paperwork they demand for expensive drugs or imaging.

We think our extra work is helping our patients, but in the big picture, they are paying a greater cost. Our system will not change until every doctor realizes that coding and billing are a violation of our Hippocratic oath. Every primary care doctor: pediatrician, internist, family practitioner, and gynecologist must stop coding and filing insurance claims. Imagine if we all did this tomorrow. Would we even know what our fees would be? If CVS can purchase Aetna, I’m sure we can organize to stop choking ourselves on their red tape. Otherwise, in fifty years the only doctors who will be able to be transparent about fees will be working for CVS.

Denise A. Somsak is a pediatrician.

Image credit: Shutterstock.com


2K Shares

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Your email address will not be published. Required fields are marked *