Excuses Here, Excuses There…

It’s bad enough that the care physicians provide their patients is discounted beyond what any reasonable person would consider fair.  Unless you are a medical coder and biller, the public has no knowledge of how the insurance companies and federal and state governments further derail their payments to physicians.

When a physician provides care to a patient, the physician must find a code for the patient’s problem which the insurance company will pay for and then submit a claim called a 1500.  That claim requires the physician to link each entry in the claim to a diagnosis which the insurance company has deemed something they will pay for (for the grungy details, see The Ubiquitous 1500). When our clinic submits a claim for $130 for a 15-minute visit by a patient, we are paid $47 by Medicaid, and about $75 by Medicare. This is something no lawyer or dentist would tolerate.  Yet the American Medical Association has never successfully prevented this from happening to physicians, although other professional organizations have managed to avoid this problem with their members.

But wait.  There are numerous reasons to reduce this measley payment even more. Suppose the patient comes to the clinic in a state of extreme anxiety.  There is a diagnostic code for anxiety, but Medicare doesn’t like to pay primary care physicans for “psychological” problems, preferring to think only psychiatrists are qualified to diagnose anxiety.  So for physicians providing family practice care, Medicare automatically discounts any diagnostic code relating in any way to psychiatric codes an additional 15 percent.

Payers provide physicians with what is called an Explanation of Benefits (EOB). Most EOBs contain a long list of codes indicating why the payer isn’t paying the claim, at least in full. This may be because the payer doesn’t think the service was justified (how would they know—they weren’t there). This may be because the payer doesn’t think whatever procedure was provided the patient was appropriate for the “point of service.”  That is, whatever procedure was done should have been done in a hospital or out-patient surgery center instead of in a clinic.

Or perhaps the insurer wont pay for a lab test unless certain diagnostic codes can be linked to the test.  One of the popular bones of contention at this moment is whether men should undergo PSA tests.  Insurance won’t pay for the cost of these tests unless the patient had a high PSA test result previously.  Doesn’t matter if a man has a history of prostate cancer in his family.  These are decisions insurance companies shouldn’t be making, but rather physicians in cooperation with the patient.

Or how about states like North Dakota which do not require insurance companies to provide contraceptive coverage for those paying insurance premiums. When patients come to our clinic, we have to write the patients a prescription for the contraceptive injection and have them purchase it from the pharmacy around the corner and bring it to the clinic where we will give them the shot.  Because North Dakota Blue Cross and Medicaid refuses to pay the clinic for the purchase of Depo-Provera for our patients. Depo-provera costs our clinic about $140. Since we cannot obtain any sort of reimbursement for this out-of-pocket expense, our only choice is to have patients purchase their own injectionable Depo-Provera and bring it to our clinic for their shots.  North Dakota Medicaid won’t even pay for the cost of the injection, much less for the shot.

Insurance companies pull all kinds of nonsense to avoid paying claims. One of our nurse practitioners reassumed her maiden name by court order.  One  insurance company refuses to pay for any claims under her previous name after the date at which they recognized her maiden name as legal. That is, any claim we submit for a patient she saw before her name was changed the insurance company refuses to pay. Even though her provider number is unchanged and her nursing license clearly indicates her name has changed, and the insurance company has a copy of the court order.

This is just the tip of the iceberg regarding what physicians have to go through to get a severely discounted payment for the services they provide.  Our clinic is small, but it still requires we employ four people full time just to process claims because the process is so draconian.

The high cost of health care lies far more at the feet of the arrogance of insurance companies and the federal government than at the feet of arrogant physicians, who, if you believed the hype from Medicare, are all trying to defraud the government.

Until the states and the federal government begin holding insurance companies—and themselves—accountable for paying health care claims honestly and without efforts to avoid payment for any underhanded excuse they can come up with, the real cause of the horrendous cost of health care will go undocumented.

It’s not the physicians.  It’s the insurance companies and state and federal payment programs, all designed to find some reason not to pay for health care services—that have driven the cost of health care beyond all reasonable levels.

Bring on the single payer system.  At least we would have only one beaurocratic entity to deal with rather than hundreds, all with different rules and regulations about what they will pay and how, there would only be one set of rules to dance around.




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