Are insurance companies in the business of curtailing healthcare costs and helping improve the quality and efficiency of healthcare in the USA? If they are, they have done a horrible job with it, as healthcare costs more in the USA than any other country. They are also telling doctors how to treat their patients while loading them up with obscene administrative burdens. These costs have been passed along to us, the healthcare consumer. Also, insurance protocols may require your doctor to send you elsewhere for a test that was much less expensive when administered in their office. There also was a time they would take your blood instead of sending you to a lab the insurance company authorized.
As many of you may have noticed, doctors are selling their practices to large hospital systems that continue to get larger and free them of many of the administrative headaches common in private practice, while making healthcare more expensive, less consumer-friendly and more complicated. It is no secret that monopolies are not good for consumers or insurers for that matter.
Recently, it has been estimated that complying with insurance companies and their rules may be an 800 billion dollar yearly problem as recently reported by Time Magazine.
While it is true that many physician-based habits such as ordering too many tests and blaming them on defensive medicine may sound good, getting these tests approved by insurers is big business. The same can be said of expensive medications. Insurance companies also own middlemen that have made drugs cost more while getting rebates from drug companies for their high priced products that are never passed down to the consumer.
Medical certification and management companies hired by insurers hide behind rules that are sort of science and study based and have doctors’ offices calling multiple times to get medically necessary care approved. Sometimes, a doctor will be approved and perform the procedure, only to have it denied retroactively which requires called to medical management to overturn a nonpayment decision.
In our world of chiropractic, we need to precertify MRI’s even though statistically, we order far fewer tests than our medical counterparts for musculoskeletal conditions. Even though we add little cost to the system, it is not unusual to initially be denied only to be approved by a doctor on the other line when we challenge the denial. This usually occurs during our busy patient schedules which can put the doctor behind.
Then there are the for-profit companies that deny or limit care such as American Specialty Health and NIA which have sold insurers on the idea that they will improve care and cost-effectiveness as well as waste. The truth is, they create cash flow problems for providers who often have to beg for additional visits to help a patient in need. Many of these companies also do the same with other medical specialties.
Some companies such as Optum are owned by the insurer (United) and underpay for the services. Many doctors resign from these plans while others who continue with them are placed in tiers that require them to go online and fill out treatment plans which micromanage the care they need to perform to help the patient. All of these methods are used to pre deny care if the doctor skips a step by accident.
Care pre denials are a big and profitable business, and it is currently estimated that it is a huge cost driver for patients and the doctors that treat them, while adding little value to the care or worse, force the patient to find other means to help themselves because their insurer either underpays the doctor or is preventing medically necessary care.
In many of these cases, adequate reimbursement with physician engagement would cost much less than our current system of denials and middlemen.
A recent article published in The Washington Post I found questions the idea of why we allow insurers to do this. Check out the article below
Insurance companies aren’t doctors. So why do we keep letting them practice medicine?
By William E. Bennett Jr.
Oct. 22, 2019 at 8:00 a.m. EDT
William E. Bennett Jr. is an associate professor of pediatrics at the Indiana University School of Medicine.
We know how important it is to have insurance so that we can get health care. As a physician, parent and patient, I cannot overemphasize that having insurance is not enough.
As a gastroenterologist, I often prescribe expensive medications or tests for my patients. But for insurance companies to cover those treatments, I must submit a “prior authorization” to the companies, and it can take days or weeks to hear back. If the insurance company denies coverage, which occurs frequently, I have the option of setting up a special type of physician-to-physician appeal called a “peer-to-peer.”
Here’s the thing: After a few minutes of pleasant chat with a doctor or pharmacist working for the insurance company, they almost always approve coverage and give me an approval number. There’s almost never a back-and-forth discussion; it’s just me saying a few keywords to make sure the denial is reversed.