As the economy continues to tighten, the level of insurance reimbursements from medical procedures continues to get worse. Amidst the presidential campaign banter is the cry for universal health coverage, talked about as if such a system would end up better than what we have now. That is an issue for a different debate, what I prefer to rant about here is the pitiful level of insurance management and reimbursement from all health insurers and the great patient misconceptions about it.
Plastic surgery has always been unique from an insurance perspective in that everything we do has to be pre-determined and pre-authorized by the insurance company to ascertain if there is a medical basis for the procedure. On the surface, I have no problem with that but I have seen a ridiculous number of medical benefits initially determined to be unnecessary including cleft lip and palate repairs in babies, fractured facial bones, breast reconstructions, and reconstruction of skull defects to name just a few.
The pre-determination process, in general, is a 6 to 8 week process which is frustrating for many patients. It usually is much longer as often records are lost or misplaced by the insurer and I have had to send in as many three separate duplicates to get a response. As a result, it can take months to get an answer. And when the patient calls the insurer to find out their pre-determination status, in an effort to move things alone, the insurers are quick to mention that it is the doctor’s office that has failed to respond to their requests for information. This is almost always an outright lie…their system is just so inefficient and disorganized that the right hand has no idea what the left hand is doing. I have seen records mysteriously appear after they ‘couldn’t find them for months’.
Once a response to the claim is returned, it will often be that the pre-determination has been denied due to insufficient information. (of which we had already sent them this information numerous times!) There is obviously a great black hole at their offices where all this redundant information must go. Then if the pre-determination is approved, there is also the written caveat that comes with it that the an approved procedure doesn’t guarantee that payment for services will be made. So they will approve it but an approval has nothing to do with payment. Isn’t that why we went through the pre-determination process in the first place?
The real entertainment begins when a bill is submitted for services rendered to the insurer. I have never seen so many imaginative ways that payment can be delayed or denied. From we don’t know who this member (not in our active insureds), we have no predetermination on this member for this procedure (even though they did pre-determine it), to one of the hundreds of numbers on the claim submission form is missing, few surgery payments ever get paid in a remotely timely manner.
Always remember doctors get paid last. Then when the payment comes 3 to 9 months later after numerous man hours of paperwork efforts and phone calls, the reimbursement rate will be anywhere from 8 to 12% of what was charged. With an often noted commentary on the paid bill to the patient that ‘your doctor charges were above the usual and customary rate’ for this procedure. A veiled attempt to make the doctor look like they were fraudulent in their charges. Contracted rates by health insurers are universally horrendous but who is it that creates this reimbursement rate? Patients are under the misconception that the doctors have negotiated these rates. Quite the contrary, contracted rates mean if you want to sign up, here is what you are going to get…period. There is no true discussion or negotiation. While it is true that signing up for any insurance plan on the physicians part is voluntary, but for most doctors who only do insured patient services, what other option do you have.
Fortunately, as a plastic surgeon, only about 5% of my practice now is insurance. But I have a hard time seeing how any further socialization of the health care system is going to improve the doctor’s experience of it…….And, by the way, if you want to speed up payments from the insurers, you can now sign up for electronic claim submission. Indeed it may be faster…but the fine print is that it costs thousands of dollars to become registered and there will be a hefty monthly hosting fee for your practice.
Dr Barry Eppley
Indianapolis, Indiana