Follow-up: An Example of Insurance Companies Focusing on Profits, Not Patients.

I received a letter today from Deseret Mutual Benefit Administrators (DMBA) re: an appeal I had filed on behalf of one of their members (our patient).  As I described in my previous post, I work very hard to provide our patients with accurate information as it relates to their out of pocket expense.  I had contacted DMBA prior to providing services to their client and was told that their plan would pay 100% of allowable charges after co-pay.  This means that the patient is only responsible to pay their co-pay, DMBA would pay the rest. Great news, right? Well, based on my past experience, too good of news.  So, we called DMBA a second time and talked to a separate representative.  She provided the same information, 100% of allowable charges after co-pay. The reason this sounds too good to be true is that our office is an out-of-network provider for DMBA, which both representatives were aware of. Logic would hold that the insurance company should know their benefit information.

We completed the evaluation and sent the billing to DMBA.  We received an EOB (explanation of benefits) along with payment. DMBA sent 60% payment on the allowable charges. I called and explained that we had been told by TWO of their representatives that they would pay 100%.  I was instructed to file an appeal.  

I received the appeal decision today.  Although DMBA acknowledges providing us with incorrect information (they reviewed both phone call recordings), their obligation is to pay as outlined in the "member handbook". So, who loses?  First off, the patient, because they are ultimately responsible for the incurred charges.  Second, the provider.  The patient made the decision to pursue testing based on the estimate I provided and may not have the financial means to pay for the services.  It is not uncommon in this situation for the patient to take out their frustration at the provider instead of where it rightly belongs, on the insurance company.

The denial letter also stated that, since the service was "medically necessary", it would have occurred regardless of the percentage the plan paid. I think the patient would strongly disagree.  They had other choices.  They could have taken responsibility for submitting the billing paperwork directly to their insurance, allowing them to be eligible for the cheaper "self-pay" rate. They could have also chosen an "in-network" provider that would have been reimbursed 100%. Everyone has a right to know what something is going to cost.  It frustrates me that in healthcare, this answer can be so hard to come by.


I still can't understand how an insurance company acknowledges providing incorrect information but won't take accountability for it.  I'm sooo frustrated!  I have offered to help the patient file their own appeal. For most patients, this is an intimating process and many just choose to pay (or not pay) the bill. 

What the Affordable Care Act Means to Me: Health Insurance Companies Focusing on Patients, Not Profits

In my first post about The Affordable Healthcare Act, I discussed what it means to me as a consumer of healthcare.  Now, I would like to share what it means to me as a healthcare provider.  My husband (a neuropsychologist) and I (a physical therapist) have a healthcare practice that provides services to individuals who have experienced some form of neurological injury (ie. traumatic brain injury) or neurodevelopmental disorder (is. Autism, ADD etc.). For many of these individuals, the long term consequence of their injury is cognitive / behavioral.  Even though the source of their problem was medical, they are now labeled with a mental health disorder.  Mental health coverage by insurance companies is typically quite poor; in many plans it’s non-existent.  There are very effective treatments but people can’t access them due to cost and availability. Without treatment, many of these individuals are unable to be productive members of society.  With treatment, they are able to work alongside of us!

So, what will the ACA do to change this?  The ACA expands the parity in healthcare between physical and mental health.  It also expands the coverage of prescription medication.  This will allow patient’s with disabling mental health diagnoses to receive appropriate care, allowing them to be productive citizens. Supreme Court Decision Benefits People With Mental Illness.

Alongside of providing services to patients, is the issue of getting paid. One of my jobs is billing insurance companies for the services we provide to their members.  Our practice believes in complete disclosure re: costs. I contact each insurance company prior to a patient’s appointment to obtain “verification of benefits”. My goal is to answer the following questions. 1) Are “x” services covered by the patient’s insurance plan? 2) If so, what portion of the service is the patient responsible for paying? The following list of variables factor into finding out the answer to these questions.

• What type of provider is providing the service (ie.,MD, Psychologist, Counselor, Speech-Language Pathologist)?
• Is the provider in-network or out-of-network?
• In what environment is the service being provided (ie.,inpatient, outpatient, in home)?
• What diagnosis are you treating? (More specifically, what diagnoses are excluded)
• What is their deductible?
• Does the service “apply to deductible”?
• How much of the deductible has been met?
• Is there a co-payment or co-insurance?
• Is pre-authorization required?

Oh, I forgot to tell you that this conversation always starts with the disclaimer, “The information provided is not a guarantee of payment.” This is why it is so important to get answers to all of the above questions. For example, if you don’t ask about exclusions and bill the service with an excluded diagnosis, the claim will be denied.  If you don’t ask about pre-authorization and pre-auth is not obtained, the claim will be denied.

After obtaining, what I hope to be, accurate information about the patient’s benefits, I can then provide the patient with an estimate of cost for the requested service. I have had several occasions where I have obtained all this information, billed the service as the insurance company instructed and it was still denied.  Then we start the process of appeal which can take months to complete.  There have been cases where we have literally lost money when it is all said and done.

The reality is, insurance companies are profit-driven; they will do whatever they can to get out of paying for a service.  As soon as you think you know “the rules”, they change.  It’s not in their primary interest to ensure their members receive needed services and even less important for healthcare providers to be paid for services.  In some cases, we can’t even hold the member responsible to pay for the service due to the fine print in the contract between the insurance company and the provider.  If the healthcare provider ends up not being paid for the service they provide, they can’t even claim it as a loss on their taxes.

Insurance companies first and foremost accountability is to provide their management structure with exorbitant salaries and their shareholders with hefty dividends. According the an article in American Medical News, a publication of the American Medical Association (AMA), insurance companies provided their CEO’s with the following annual salaries in 2011:

• Aetna: $14 million
• Coventry: $13.6 million
• Wellpoint: $13.4 million
• United Healthcare: $10.1 million
• Humana: $6.1 million

What is the ACA going to do to change this? Most importantly, it will require insurance companies to make providing healthcare to their members their first priority.  Insurance companies must now spend 80% of premium dollars collected on healthcare costs.  The remaining 20% can be used for administrative cost, salaries, advertising etc.  If an insurance company does not comply with the 80% guideline, they must provide rebates to the members.  It is estimated that insurance companies will be paying an excess of $1 billion dollars in rebates to their members this year. Insurers Say Health-Reform Related Rebates To Exceed $1Billion.

I welcome questions, comments, experiences!  Please share.  My goal is to create a dialogue.

What The Affordable Care Act Means to Me: Personal Accountability While Allowing For Accommodation

Why do I care about affordable healthcare?  First, I’m alive therefore I am a consumer of healthcare.  Second, I have been a healthcare provider (physical therapist) for 16 years.  Third, my husband and I are small business owners and have made the commitment to provide health insurance to our employees.

In the 38 years (almost 39) that I have been alive, I have never been without health insurance.  The thought freaks me out.  I have been in the position of making a choice about where to spend my money and health insurance has trumped many things over the years.  But I also have never had a major health crisis, nor have I ever been unemployed.  Yes, I could puff my chest out and say I’m better than “those people”, but I know better.  The reality is, those circumstances are a moment away.  They are for everyone. 

I have seen / worked with individuals for whom that moment has come.  They have spent their lives being responsible, law abiding, GOOD people but something happened (health crisis, accident, job loss etc.) and the rug was taken out from under them.  I worked with a woman once who too had health insurance all her life.  After 17 years with the same company, she decided to take a temporary leave of absence for a couple of months.  One month into that absence, she had a cerebral hemorrhage (a blood vessel in her brain burst).  Her family had retirement, saving etc. but the expenses quickly piled up and that was spent. Her family had to file for bankruptcy due to her medical expenses. 

At one point in my career, although I was employed in a job I loved, health insurance was not provided. I had previously been covered by my husbands health insurance.  We divorced and I was no longer eligible for his insurance. In order to obtain health insurance, I quit a job I really enjoyed to take a job that offered health insurance. Several years later, realizing I wanted to return to job setting I really enjoyed, I contacted my health insurance company (who had been my insurer since graduating college) about obtaining an individual health insurance policy.  The only plan I could get was for catastrophic coverage.  I had faithfully used my preventative benefits but had never had a major expense. I was floored.  My thought was, “I am 34 years old, healthy and this is the only plan I qualify for?” Health insurance was now dictating my career path.

So, what will ACA do to change this?

• Individuals will have access to affordable individual health plans through the Exchanges that will be created as a result of this law. This exchanges will will carry affordable healthcare options by private insurance companies.
• Individuals, who use to have to forgo any coverage because of cost, will now be able to afford good health insurance.  This will prevent them from needing to use indigent services or government sponsored health insurance.
• Second, if you have a pre-existing condition, you cannot be denied health insurance, forcing the individual to use indigent or government sponsored health insurance.
• If your healthcare becomes costly, your private health insurance cannot drop your coverage, again forcing the individual to use indigent or government sponsored health insurance.
• If you are age 26 or younger, working to establish yourself as a responsible adult, you can stay on your parent’s health insurance until age 26.

Some thoughts on the individual mandate, the most controversial point of the legislation. People still have the right to choose to not get coverage.  If they do, they will then be required to pay a penalty (or not, depending on circumstances).  This penalty will be put into the government coffers to be used to pay for their healthcare when they require it (lets be real, at some point everyone requires it).  Isn’t this the logic used when they instituted a tax on cigarettes? As a former smoker, the smoking tax always made sense to me. If you smoke, you should pay more tax because smoking increases your healthcare cost.  If you are alive, you will require healthcare therefore you should be taxed to offset that cost.  It’s all about choices and accountability.

An example.  I worked with a man who was a successful real estate agent.  He chose to spend his money acquiring lots of stuff (cars, electronics, etc.) He also chose to not buy health insurance.  While he was spending the weekend at the lake, he chose to dive into the lake, head first and broke his neck.  Because he didn’t have health insurance, nor did he have any liquid assests, he qualified for Medicaid. Maybe, had the mandate been in place, he would have thought twice about getting health insurance and would not have ended up on Medicaid.  Or, he could still have chosen to not get health insurance and would have contributed to the government through the penalty.

In my next blog I will talk about my role as a healthcare provider in the context of the ACA.  Any thoughts? Questions?  Please leave a comment!  My goal is to inform and there is a lot of misinformation floating around.