Health insurance companies fly in the ointment tactics, and how to win the game.

I was at an insurance seminar yesterday which talked about how to win at reviews and how to prevent insurers from taking advantage of us. Health Insurance companies have a business model that increases profits by using algorithms to deny valid procedure codes or entire claims to boost profits.  Like all of our patients, doctors have expenses and employees who must be paid weekly. In the case of chiropractors, Insurers such have Aetna have repeatedly denied needed evaluations, and codes for regular procedures and created recertification programs whose only purpose was to frustrate both them and their patients while limiting medically necessary care. Aetna recently disbanded its precert program with NIA/Magellan after years of complaints by both patients and doctors in NJ. Essentially, the game had run its course and the program that provided no value in care but had doctors arguing with NIA for more units of care was likely costing them money. Patients often found themselves in the middle of this as the doctor did their best to help them with NIA standing in the way of reimbursement.  Ultimately, the cost shifted to patients for what NIA refused to allow.  Years of complaints to DOBI (Dept of banking and insurance) finally forced Aetna to get rid of NIA. They do this with other medical professionals as well which is forcing doctors out of private practice, reducing competition, and making hospital systems grow even larger.   It is part of the game of for-profit healthcare that has been ruining healthcare for years. According to the insurance expert teaching the seminar, if doctors do not appeal these denials and don't file complaints in large numbers, insurance executives will not change anything as it saves them millions of dollars.   Starving your local doctor for revenue is how they keep in-network doctors from doing appeals since this requires both time and employee hours.  He explained; Once enough people complain or file appeals to DOBI, our professional Associations' meetings with these insurers can over time elicit change. By then, the damage has already been done to the practice, to the patient relationships, and to our trust in the system. Pro Publica recently reported on this as well. Doctors are in-practice to help people and are public servants.   The idea that health insurers can on a whim change the rules to increase profits is a fraud that they get away with daily. A single-payer model that eliminates middlemen doing this purely for profit while making a mess out of the system already exists in the USA and it's called Medicare. Horizon Blue Cross Blue Shield, the largest insurer in NJ will periodically send a letter to participants asking them if they have secondary insurance and will stop paying any claims until the person responds, frustrating doctors who again will not get paid.  They will also audit doctors for note compliance although in many cases, they merely cause more stress on practices trying to do their best not taking and reporting while they are doing their best just to survive in a crazy healthcare environment. It happened to us years ago and we won on appeal. They also introduced tiered plans that reduced your cost for higher priced hospitals and providers while making lower cost-effective providers cost more under their Omnia plan. United Healthcare under its subsidiary Optum Health has its own methods of doing this.  Years ago, they were underpaying chiropractors for their work on extremities until the AMA reviewed the practice and found that they were interpreting the procedure code improperly and only paying the code with a modifier of -51, reducing the reimbursement by half of what their fee schedule allows.  This was appealed to the AMA who ruled that they used the modifier improperly to reduce the reimbursement and in 2014, optum reversed this policy.  Doctors of chiropractic were never reimbursed for the many years they were underpaid and then they moved to a global fee system that no longer pays doctors for their exams.   They also require a precert and an internal tiering method which is designed to give them data but at the same time, again frustrate doctors trying to help others. Ironically, they have been telling the world how much chiropractic care saves them in healthcare costs. Patients too encounter this when we send them a bill.  They want their doctors to be paid. Usually, a bill arrives after an insurer has behaved badly and not paid the valid claim.   Patients often have more influence than their doctors do. The situation is even worse with self-insured plans under ERISA since these plans do not need to observe the rules under DOBI.   I have seen them red flag legitimate clean claims with good documentation only to frustrate the doctor and eventually, the patient who received the bill for non-payment.  Erisa plans can save employers money since they are the insurer and hold the funds rather than the insurance company that lends them their network and processes their claims. Fighting them, however, is more difficult as they adhere to national Erisa rules rather than state insurance departments. Healthcare is expensive in the USA, and when an insurer goes to great lengths to make it both time-consuming and frustrating, they often win when we the consumer do nothing to fight back. Their activities have steadily driven healthcare prices higher.

The insurance middleman game

When you visit a healthcare provider, the insurer is nothing but an expensive middleman.   To make matters worse, the networks have people looking for people who participate instead of being able to just go to the best provider. It is also becoming more common for an insurer such as the one USAA uses for their auto claims to use a third-party company to perform pre-certifications, perform medical reviews, and process claims.   Recently, USAA's insurer did just this using a problematic third party called Auto Injury Solutions (AIS).   Over the years we have worked with them and currently, the patient's account has been in arrears for months even though an independent medical exam ordered by the insurer approved all the care, which we had in writing.  Currently, he is getting the runaround and I got personally involved.  I spoke with the nurse who went through each date but had no explanation as to why the claims were unpaid other than a doctor's opinion on the medical necessity that had already been established.  They would not override the doctor's decision even though the doctor's decision said the claims should be covered.   The nurse's supervisor gave us the same nonsense and the adjustor kicked this to a supervisor who never called us.  Then they told both our office and the patient that we failed to precertify the patient a second time when in fact, our records proved that they received the precert and did not act on it while waiting for the independent exam. I got the patient involved and suggested he demand a supervisor and put this out on social media for all to see. We are still waiting for this to resolve but this back-and-forth nonsense is how they wear out both doctors and patients. Allowing them to succeed in non-payment of this valid claim is not an option as it proves to the insurer that this type of behavior saves money, which is their sales pitch to the insurance company hiring them. Ultimately AIS is a middleman's middleman. They win, we all lose.  If they lose, the insurance company will use someone else or do this in-house. American Specialty Health uses tactics such as in-network chiropractors being underpaid, many services being automatically denied, notes being ignored and out of network, they get in the way by doing the same nonsense.   They have been sued for doing this in NJ.   They are also a middleman's middleman.  They have made themselves and others a fortune with these tactics and nobody has yet been able to shut them down.   They do nothing to improve the quality of healthcare. They were sued for doing this and had to pay chiropractors 11 million dollars.   This did nothing to change their business model and they continue to aggravate patients and their doctors and are likely the reason so many experienced doctors refuse to participate with them in NJ. There has never been a stronger argument for single-payer healthcare than these middlemen who make a fortune while making the US healthcare system more of a frustrating mess than it already is.   Other methods such as tiering, no out-of-network coverage, and high deductibles have raised the cost for all of us while making the experience even worse, leaving you with little recourse.

Patients ultimately need to be their own advocates.  Here's how to advocate for yourself.

• The unpaid claim that is legit?    File a complaint with DOBI in NJ and then call the insurer and ask for a supervisor to pay the claim.
• Work with your treating doctor and continue to treat if necessary.
• Be aware that you may have more influence than your doctor does because you are a subscriber.
• Take no prisoners, as they don't.   Insurers will place many obstacles in the way for you including asking for notes.   Some larger offices will be as bad as insurers and it may seem that they don't care, but they know how to send bills.

Insurers do this in all sorts of businesses.   It does not belong in healthcare and is inflationary,  It has also forced many doctors out of business or into working with large systems making care less personalized and mediocre. It is all of our responsibility to fight back.   These business models are no longer profitable if we make it cost them money.  Appeals and complaints will do that.