Saturday, February 3, 2007

Why Doesn't My Doctor's Office Take My New Insurance Plan?

Many people who get medical insurance through their employer have had the experience of the plan being changed by their employer from year to year. Usually the employer does this to save money on the premiums that they pay on behalf of the employee, and any other considerations are of a very secondary importance. This can be frustrating to employees, however, who may find that their personal physician either does not accept the new insurance, or is not a "preferred provider", which means that they will have to pay more for their care. Why don't doctors take every insurance? Here is a recent story that I am familiar with here in the Northwest.

A prominent employer was recently purchased by a new parent company, which made the decision to change the employee medical plan as part of cost savings measures. This medical plan they chose was not very active in the area, and so the plan gave the employer a very inexpensive price to try and "buy their business" and get a foothold in the community. Trouble was, very few doctors in the community had signed up with that plan. The local doctors were not consulted as to why they did not participate, and the employees of the company were not involved in the decision. It probably never even occurred to the company officials that their action might affect others in the community. Either that, or they did not care.

Suddenly, doctors were confronted with hundreds of their long time clients who presented their plan and asked for the office to sign a contract with their new insurance. It turns out that the doctors offices had not signed up with this company on purpose, due to the way the plan did business. Anxious to learn if things might have changed, one doctors group undertook a survey of medical practices in other areas that were already working with the plan. They learned that working with this plan was a disaster. Here are some of the specific problems they uncovered:
  • Doctors offices were forced to call customer service lines that were almost always busy, making it difficult to ask questions and get assistance
  • Customer service would frequently "transfer" calls which then became disconnected, starting the cycle of trying to get through again.
  • Customer service would frequently say they are going to reprocess a claim that was "lost" but then it would not happen
  • Most customer service calls are handled from India or Jamaica, by individuals who could not make a decision or really help. Often there is a lack of understanding from the person due to language barriers.
  • Payments for doctors services were artificially low, and grouped services together, only paying for one of them
  • Large, multispecialty clinics that could profit from expensive tests and procedures signed up and could afford the losses in primary care because they were able to make it up on their high ticket items, but the primary care clinics could not make it pay
  • The company's corporate practices often drove a wedge between the patient and the physician on several levels such as:
    • Inefficient claims process that loses claims but insists they were never billed and then blames the doctors office to the patient who complains
    • Requirements for multiple pre-authorization requests from the doctors office, even for routine care, but then hours are wasted trying to get through. An example is the requirement that the doctors office call them when a patient is in the hospital or is diagnosed as being pregnant. If this is not done "right away" then the later claim for care will not be paid
    • The plan created a business climate in the area that reduced medical insurance plan availability, since the other plans could not compete with the artificially low prices
    • Some states have already enacted legislation against this company because of some of their "predatory" business practices
The particular group in question decided once again not to participate with the plan, because to do so would jeopardize their own business and encourage employers to choose the plan. They do try to help their patients, however, by submitting a bill to the insurance company on behalf of the patient. If the claim is not paid, they then transfer it to the patient who gets to deal with their company directly to try and work things out.

Behavior like this from insurance companies is one reason why we have 50% less medical school graduates choosing to go into family medicine than we had when I made that choice in 1975. I believe that employers and citizens need to be more aware of how their choices affect the health care delivery system that they depend on for their care. Our health care "system' is a mess, precisely because of nonsense like this.


Anonymous said...

This makes so much sense. As patients we don't want our health care providers to have to micromanage our billing and insurance regimines, but as employees we are stuck not having a choice in our insurance providers. The disconnect between the client and the provider is part of the problem in medical care today, and your description of this particular conundrum goes far to illustrating to the patient the mechanism of what is going on behind the scene.

Thanks for getting out the message!

Tavia said...

This is great info to know.