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
