Why Some Physicians Do Not Accept Insurance

I admire bloggers who can come up with something to post each and every day.  For all the time I have been posting to The Treating Physician, I seem needful of down time, time to rest, reflect, and let whatever chaos is out there take it’s course before once again slogging in to try to present a perspective on one representative of the health care dilemma that is so poorly, often disparagingly represented in the media.  Physicians.

For all the gnashing of teeth and wailing at high costs of health care, no one, absolutely no one, is seriously looking at where a large chunk of health care dollars go. So no one is even collecting the data.  So the bleeding goes on, but unnoticed by those responsible for tracking it.

Let me propose that all those studying where this country’s health care dollars are going accept the notion that corporately owned physicians no longer have any real control over the care they provide their patients. Yes, that means they are often unable to make medical decisions in the best interest of patients. Health care policymakers, cost reduction specialists, and especially the media chasing the latest medical sound bite seem unable to phathom this reality.

Physicians are often accused of ordering too many tests.  In reality, tests are often ordered based on whether they will be paid for by third party payers, not based upon whether or not they are, from the physician’s point of view, actually needed. In the corporate medical environment, those tests which aren’t covered by third party payers are not ordered, even though the physician may feel them necessary.

So, bean counters need to investigate the real decision making process in health care today and move beyond the notion that physicians order too many tests. Instead of physician decisions to order tests, the investigation should be of corporate incentives to order tests that will be paid for which generate increased services within the corporate health care entity. The public needs to understand that in large medical corporations, referrals for additional services generally go to some practitioner within that corporate entity.  Even if the best practitioner for the job works elsewhere, or practices independently.  Physicians in large medical corporations can be fired for referring patients out of network.

Now, let’s stop fussing about physicians ordering too many tests. There are many reasons this happens, and those studying health care need to look at the whole picture, not just the fact that a practitioner’s name appears on the test orders.  There are far more serious problems underlying health care costs in this country.  Physician reimbursement is one of them.

No one spends much time looking at what many practitioners must go through to get a modicum of payment for the care they provide.

In order for a physician to be paid by Medicare, Medicaid, or insurances, the physician must apply to each one individually to be “credentialed,” that is, be added to the list of providers they will pay for services rendered. If the payer accepts the practitioner’s application, the physician will be presented with a contract which must be signed before any payments will be made. This contract states that the practitioner’s charges for services will be “adjusted” by the payer for whatever amount the payer decides (and the amount of adjustment is not stated in the contract—only that it will occur).  It is, quite simply, a deep discount from the standard and usual cost of, for example, an office visit. The term adjustment is a euphemism.  Extortion more accurately describes the reality of the process.

For example, in areas where the standard fee for an office visit is $130 (designated detailed, or sometimes listed as 15 minutes), the insurance company automatically reduces the reimbursement for this visit to $80. Medicaid in North Dakota automatically reduces the payment to $40. Furthermore, the contract signed by the physician for the privilege of actually providing care to patients strictly forbids the physician from collecting from the patient the difference between the actual charge for the office visit and the discounted payment received from the insurance company.

Now, the practitioner could refuse to accept the discount, but then the insurer will refuse to “credential” the practitioner. Is it any surprise that more and more practitioners are deciding it isn’t worth it? Practitioners might as well collect the discounted payment up front from the patient and skip the tedious, time consuming, and expensive process of filing claims for deeply discounted payments.

How many consumers go to a grocery store and expect to pay $1.80 for a gallon of milk which costs $3.00?  Or go to a gas station and pay $3.60 for a $6.00 gallon of gas?  Actually, any consumer attempting such a thing would likely be considered a thief.

The discounting of physician reimbursement for the care they provide patients is obscene, and shouldn’t be tolerated.  No other business is expected to provide services for 40 percent of the actual charge. Lawyers don’t. Neither does the IRS. So the questions remains, why has the federal government allowed third party payers to virtually steal from physicians?

There’s more, much more, to this story. As I slog back into the center of health care costs, I will explain more about the underground world of physician reimbursement.  Perhaps this will begin to shed some light on the real reasons more and more physicians, particularly physicians who practice independently, are considering no longer accepting payments from Medicare, Medicaid, or health insurances.

dhaugen
Some young HR person once looked at my CV and asked me, quite seriously, if I had really done everything I had listed there. Well, yes. Because I am someone who can't sit in a Morris Miller cubicle every day, much less for any great stretch of time. Once the problem is solved, I get bored and I'm ready to move on to the next challenge. This hasn't afforded me any great stability in my work life. I simply arrive in places about ten years ahead of time. So far, at least, that penchant for early arrival hasn't been accompanied with a pocketbook full of door knobs.
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