Imagine going to a restaurant and being given a menu.  You are ready to order and meal, and fully intend to pay for it, but when asked about the prices (because there are missing) you are told by the owner that you are not entitled to that information.

Now this scenario is actually better than what your insurance companies consider normal.  In the restaurant model, you are not paying a monthly premium for services that you expect to be rendered.  In the restaurant, you can get up and walk out, walk down the street and sit at another establishment to get the meal you expect for the price you are informed of up front.

This discussion is about the elusive Fee Schedule.  This is a point of contention for many doctors and unfortunately ends up giving many patients grief.  Ultimately it is important to remember that the consumer controls the deck, and if you as intelligent consumers demand Fee Schedules of your insurance providers and demand that your physicians are given detailed fee schedules as well, things would change.

The problem is that when you see your doctor, you are under the impression that you have insurance, so you will only be responsible for specific costs that you were informed of by your insurance broker or agent.  Costs like co-pays, deductibles, and co-insurance.  The thing that everyone leaves out is what is the fee schedule that these costs are calculated from? Most of our patients come to our practice because we provide a service, at a level that far exceeds any office they have been to before. We pride ourselves on this and are humbled by the thousands of patients who come to us from all over the globe.  And as I have discussed in previous articles, the formula to excellence and high quality care is simple… low volume.  To make this happen we choose to stay out of network with most insurance companies.  This however, places our practice in a precarious position.

Being out-of-network means we are not contracted with insurance companies and do not agree to participate with their restrictive activities.  To limit their costs, insurance companies play an unfair game of penalizing their insured if they choose to go to an out-of-network physician.  Now here is where it gets interesting… let’s say you are okay with these shenanigans because you really want to be at a high quality facility like ours; you are entitled to know what your out of pocket expenses would be… right?  According to the insurance providers, you are not.

Every week, we spend hours on the phone conference calling with our patients and their insurance providers demanding that the insurance provider play fair and give a clear fee schedule to the insured so that they can know in advance what they can expect to pay out of pocket for the expenses of their procedures.  We do this because we feel strongly about this issue.  The insurance company works for you.  You pay them a premium and they in return are providing you a service.  The fact that they consider it acceptable to restrict your access to their Fee Schedule is a clear indication how they perceive their role in this relationship.

We conference call with you because the insurance company has call center employees answering the phones who have no vested interest in your well being.  There is no reason for them to help you get quality care, after all, they are not providing you the care, we are.  They are only the middle man determining where your premium dollars should go.  When we get on the phone with you, the insurance company cannot get away with snowing you with terms you are unfamiliar with and explanations that make no sense to the patient.  Rather, you have an advocate on the phone with you that deals with insurance companies every day and is going to serve as your liaison, standing up for your rights.

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I’ve been told by colleagues and patients that I take this insurance thing way to seriously.  There is a reason for this.  The health insurance industry has been instrumental in destroying the quality health care system our country had.  They have controlled both sides of the field and have created a closed market that doesn’t allow for quality care to flourish without restriction.

As an ethical American, I cannot cower and let this continue.  An article published in the Wall Street Journal, June 25th, 2009 outlines how United Health Care and their subsidiary Ingenix Inc. underpaid doctors and hospitals who were out-of-network due to flawed databases.  It is crucial that you understand that Ingenix acquired the Lewin Group who released the most optimistic assessment to date of President Obama’s health insurance reform plan.  Lewin is a leading source of independent, nonpartisan health policy analysis for the U.S. Government.  Despite assurances given in June 2007, however, no corporate policy has been written to protect Lewin from interference by it;s parent companies… Ingenix Inc., which is United Health Care.

This form of corruption has to stop.  You as the consumer can stop it, and you can count on us to support you.

You’ve had a chance to consult with us, you’ve visited the web site and done your research on modern surgical techniques for bunion surgery, you have health insurance and are ready to schedule your procedure… so what now?

There is a lot more that happens in the background that you are not informed of.  My goal is to shed some light on the process of how insurance companies operate and how they deal with us, your health care providers, so that my patients, and thousands of other Americans can be well informed consumers when choosing a health insurance policy, and more importantly, what to demand from their insurance providers.

Most health insurance companies are large “for-profit” corporations.  This means that in order for the company to increases profits, they must either lower reimbursements to doctors, or raise premiums for the insured.  To bring reimbursements down, insurance companies tie contracts with doctors to perform procedures for a discounted rate.

This ultimately effects the practice of medicine in a negative manner since the cost of practicing medicine, and operating a business continues to go up.  The result is doctors’ offices have increased the volume of patients they see and procedures they perform in a day to cover always increasing costs, and reduction of reimbursements.

Since it’s inception day, Beverly Hills Aesthetic Foot Surgery has been committed to the practice of excellence and quality in Podiatric Surgery.  To achieve this, I have committed to a small footprint high quality practice.  Where other offices have 4 or 5 treatment rooms, we only have two.  Most practices in the U.S. currently contract with one or more of the major insurance providers (this continues to contribute to the reduction of quality of care that is derived from increase in volume); we only contract with non-profit insurance companies.

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Contracting with insurance companies means you have to see more patients per day because of the reliable reduction in reimbursements.  Increased volume means decreased quality.  Not an acceptable equation in my practice.

So I saw it as an ethical decision, and decided to cancel all of our contracts with for-profit insurance providers.  You might be asking yourself, as many of our patients also do: “Can I still be treated at your office if you are out-of-network or not contracted with my insurance provider?”  Yes, you can.  Most insurance plans offer out-of-network coverage, giving you the power to decide who treats you.  This is something you should demand and expect from your insurance provider.   This keeps the system honest but more importantly it gives the patient the power to decide what they consider a quality practice and who they choose as their doctor.

We pride ourselves on educating and helping our patients in every way possible to ease the navigation of the quagmire the insurance industry has created.  We often serve as patient advocates and conference call with insurance companies to expose the unfortunate and unacceptable mediocrity they perform their duties with.

Our ethics don’t stop with contracts though.  Clear pricing and up front transparency on the costs of your procedure is another tenet of our practice.  This would be simple if the insurance industry played fair and gave their clients a copy of the Current Procedural Terminology (CPT) code book and the payments they allow for each code.  Just like when you dine at a restaurant the prices are marked clearly so you know in advance what the items cost.

We are not so lucky in medicine.  Insurance companies regularly restrict access to the fee schedule and clear break down of expected payment.  This limits our ability to give our patients what they rightfully deserve, a clear breakdown of their expected out of pocket expenses before surgery is scheduled.  The hidden fee schedule is another sad result of a for-profit insurance company.

This is why I urge every one of you to call your insurance companies and demand that they release a complete fee schedule to you so that you can be aware of what your costs will be before you consider treatment.  This expected reimbursement model is followed by every other facet of insurance except for health.  Consistent with our patient centric philosophy, our practice operates with open transparency.  Upon your request, we will give you the codes that we will be billing so that you can have the exact cost for your procedure (given that your insurance company complies with your requested copy of the current fee schedule).

This saddens me because in the end, we the consumers lose.

My promise to you and every future patient is that we will stand resolute giving our patients what they rightfully deserve:  the practice of podiatric medicine at the highest level without compromise in personal attention, technological advancement, or procedural innovation. I believe in this so much that I had it painted onto our OR wall…

Health insurance is one of the hot topics every election year.  Our new President has committed to reforming health care.  At this time, 1/8 (47 Million) of Americans are uninsured.  The reasons for this are complex.  Our system is based on a privatized model that operates on a for profit system.

This article is the first of a series of articles designed to educate and empower readers and patients to fight back against the mess that the insurance industry is causing for health care in America.

Most patients are not informed of what their plans cover or what the implications of switching their plan to an HMO or Managed Care program are.  Most doctors are too busy to educate and spend the quality time needed to get to know, and build relationships with their patients.  The whole thing translates to a viscous spiral that can only lead to catastrophe.

I feel that informing the public is the first step to fixing the problem.  The public can change the insurance market by driving the demand for products in the direction that serves them and their doctors in an ethical manner; the polar opposite of what is happening today.

Out-of-Network vs. In-Network Doctors

The big insurance providers of this country are running a business that has controlled medicine for the last 25 years.  Cornering the market was easy for these massive corporations.  When contracting to become an “In-Network” doctor first came into vogue, most insurance companies paid doctors on a fair market, or relative value scale.  But when contracts started to bind doctors into a fixed pricing schedule the demise of quality coverage began.  Insurance providers played both sides of the fence.  Now, a typical insurance provider like Blue Cross Anthem will force patients to see In-Network doctors by penalizing them if they see non-contracted, Out-of-Network doctors.  They also punish doctors by not listing them in the “Preferred Provider Book” if they choose to be Out-of-Network; but what you don’t know is that these “Preferred Providers” are doctors who have signed a contract with Blue Cross agreeing to work for significantly less payment for the services they provide.

This happens because most doctors graduate with debt and they need to start practice with some kind of revenue stream.  The typical graduate from medical school owes around $180,000 for their education.  Combined with the costs of starting a practice, signing a contract with one of the big insurance companies to work for a 75% cut in payment is an attractive offer when your loan note is due in a month.

So big insurers have captive audience on both sides of the fence, the patient is punished if they go out of network, and the doctor is punished by being paid 25% percent of what they are worth, if they are in-network.

I often talk to patients about this on going problem.  I ask patients: “what has happened to your insurance premiums in the past few years?  They’ve gone up right?”  But if you take a close look at your EOBs (Explanations of Benefits) you will see that the reimbursements to doctors has gone down every year.  When I first started practice I remember going through some old EOBs from my senior associate and I was shocked.  A standard bunion procedure is now paid at 50% less than it was in 1981!  Think about this for a second; what has happened to the cost of living and every other cost in the last 20 years?  But the reimbursement for procedures is consistently being cut.

Combined with consistently increasing premiums, you and I need to be asking “Where is the money in the middle going?”  Insurance companies answer with “the cost of health care is going up as more Americans are getting sicker.”  But that’s not true.  Except for modern “lifestyle” illnesses like diabetes, obesity, heart disease and cancer, we are the healthiest we have been in the history of our country.  Illnesses like malaria, tuberculosis, small pox and other life threatening conditions are almost unheard of in today’s world.

Last year, I decided to take my practice Out-of-Network with every insurance provider.  Not because we wanted to make our patients pay, but because I consider it unethical to be tied to a contract that financially controls what, how, when and why I am paid for my services.  I pride myself of providing the best that Podiatry has to offer.  Surgical techniques that are cutting edge, and facilities that are second to none.  But when Blue Cross Anthem or other providers started to give us a hard time getting paid for services that we had already provided, I decided the buck had to stop here… regardless of the economic impact on the practice.  Most doctors increase their volume to make up for the reduction in payments.  For my practice however, that has never been, and will never be an option.  Quality must, and will always come before volume.  So we canceled our contracts with all major providers.

What does that means to you as a patient?  Not much.  We still see patients with insurance, except now that we are not bound to a contract we can provide for services on our terms rather than then insurance company’s profit driven terms.  Our patients now enjoy longer visits with more comprehensive care.  The take home message is that just because your doctor is Out-of-Network, it doesn’t mean that you can’t be seen or treated.  Rather, you will probably receive a higher quality of care and have a better experience.

Unfair Payment Practices

Since the beginning of my practice, running an ethical business was the tenet that drove every decision we made.  I developed the Environmentally Proactive Practice (EPP) initiative which now serves as a platform for other practices across the country to function in an environmentally conscious manner.  But ethics also has a key role in the financial practices of our business.  Unfortunately, your insurance provider probably doesn’t adhere to this principle.

In the current model of payment, insurance companies act like an intermediary.  The relationship between the service provider (doctor) and the recipient of services (patient) is broken by the insurance provider.  Let’s consider a “normal” situation where there is a exchange between a provider of service and a client.  Imagine going to dinner at a fine establishment and ordering their famous Chilean Sea Bass.  The meal is prepared, served and you enjoy a wonderful dinner.  At this point you are presented the check, however before you pay, you ask the owner of the restaurant to provide you a document to prove that the fish you ate, was indeed Bass from Chile!  What would happen?  You would probably be doing dishes or having a conversation with a Police officer.

Although this situation seems strange, it happens every day to doctors.  When you see your doctor, the treatment and the services are rendered.  The doctor then bills your insurance company for the services provided.  The ethical and correct series of events would be for the doctor to be paid promptly since you diligently pay your premiums expecting your insurance company to pay your doctor.  However, more and more insurance companies are doing something else.  Without any cost to them, insurance companies will send a form letter requesting “documentation” of the services rendered.  This translates to “we don’t believe you did what you are billing us for, and we want to see a document stating what you did in detail.”  This is analogous to the Sea Bass situation.  The irony here is that most of the doctors are contracted and providing the services for a discounted fee anyways; but despite the discounted agreement, and the contract, insurers like Blue Cross do not trust that your doctor is honest in their billing and request documentation.

This is sad because for a large insurance company to send out a request for documentation, it costs no more than a stamp.  All of these letters are form letters generated by a computer automatically when the bill is received for a particular treatment code.  But on the doctors end, this costs money.  Someone in the office has to take the time to prepare the documentation, send it back to the insurance company, and now wait even more to get paid; and let’s not ignore there is a big if here.  The documentation is sent to another doctor who work with the insurer.  This doctor is paid for their services to review claims.  The bottom line is that their job is to save the insurance company money and deny claims or reduce claims based on a lack of documentation.  So they are being paid to find any possible loophole to not pay the claim.

Now, I’m not sure about you, but no matter how you slice it, it seems like unfair payment practices to me?  Imagine I you decided to pay the insurance company in this manner; what would happen to your policy?  Cancellation is a word you would have to become familiar with very quickly.

The only way we can change health care in this country is to step up to the plate and participate in the actual process of being a real American.  Questioning your insurers and getting on the phone arguing with them on behalf of your doctors, and being a physician advocate is the only way to reverse this ugly trend.  The insurance company banks on the lack of financial relationship between the doctor and the patient.  If you placed an insurance company (imagine if you will a “food insurance company”) in the Sea Bass example, you would have already eaten your meal, and paid your premiums to your insurance company, the restauranteur would have already provided the services and bought the supplies for your meal, and the insurance company would have already collected your premiums.  The only person in this triangle that is not paid fairly is the restauranteur.  They now have to run after their money until the insurer deems their evidence is fit for payment.

I highly recommend you take the time to write the California Department of Insurance and complain about these practices.  Remember, Blue Cross doesn’t provide health care, your doctor does.  Blue Cross holds everyones money, and chooses when and who to pay it to.

Visit the California Department of Insurance Web Site to file a complaint at:

http://www.insurance.ca.gov/contact-us/0200-file-complaint/index.cfm

Or write a letter, or make a phone call.  Here is the contact information:

California Department of Insurance
Consumer Services Division
300 South Spring Street, South Tower
Los Angeles, CA 90013
Phone: 800-927-HELP or 213-897-8921

This section of the site is designed to provide the tools to get the most from your health insurance plans for the advanced surgical procedures we offer.  Health insurance is a daunting process that is confusing for even the most seasoned billing agencies.  My goal is to write a series of articles that will help you understand why your health insurance companies won’t give you straight answers, why they won’t pay fairly or on time for your surgeries, and why we choose to be out-of-network with most insurance companies.

As always, we are patient advocates before anything.  I take great pride in the team that I have assembled in our office to assist you in getting your claims paid, and make your surgical experience as pleasant financially as it is post-operatively.

If you have questions regarding your insurance coverage, questions regarding statements or Explanation of Benefits (EOBs) you have received, you can email our finance department at: holly@beverlyhillsfootsurgery.com