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.