Healthcare – Things you need to know
This article will not include names of doctors, patients, specific insurance companies and or IPA’s. It is written with the sole intent of informing the reader about some of the things going on in the world of healthcare today and is not intended in ANY way, shape or form to be slanderous of any specific company, group, facility, insurance payer, provider or organization.
I work for a small group of specialists and I handle all of the insurance forms, procedures and the like. However I also do back office patient care as well. By all means this does not make me the leading authority on healthcare and health insurance; but it’s shown me enough to open my eyes to the inner workings of the healthcare system enough to really make an impact.
I. Insurance
a. All Insurance is wonderful insurance – until you try to use it.
That saying has stuck with me; playing in the back of my mind every single time I hear a patient try to tell me – ‘my insurance is great they’ve always paid for everything’ the next thing that goes through my mind is that’s because you haven’t ever needed a specialists services. As long as you are doing as all insurance wants you to do, which is visit a family physician (aka. PCP, primary physician, General practioner) for checkups so they can say you’re doing well and getting your routine mammogram, prostate check or what have you, they are keeping a huge majority of what you are paying them and paying the provider their carved down, penalty deducted tiny percentage of what the service was actually worth. It’s when you are found to have a serious problem; something like breast cancer, pancreatic cancer and so on that you have now become a huge risk to them and then they begin their hunt. They will look for anything in your past history or bills that isn’t right, and when I say anything I mean anything; maybe you got a prescription for an expensive drug and failed to mention it to a nurse or doctor one time (for any reason whatsoever) – that would be something they would love to find. Subsequently they may have grounds to cancel your coverage just for that.
b. Call three times – get three different answers (PPO Specific)
Many IPO’s utilization departments are on a constantly shifting routine of what answers they will give, what they are trying to deny that day, and even what name they will use. Say for instance I call and need to pre-certify and fairly routine outpatient procedure – someone named Dave C. answers the phone, takes all the information and determines that the services are not a covered benefit of your policy. If I know from my experience this procedure is standard of care for the given diagnosis; you know what I learned after awhile? Call again, you’ll get someone else – and you may or may not get a different answer. Now if this is the case I call a 3rd time just to verify that it is the correct answer, if the third time I call the answer changes again; guess what I am forced to keep trying – moving higher up the ‘supervisor’ chain until I find someone who will give me a semi-honest answer (hard as I try this effects patient care, and makes the office look bad through no fault of its own).
Now take for example you actually had a policy that actually excluded such routinely covered services (and yes it is not uncommon to run into certain insurance plans to do) I have to call you and tell you that it is not covered, and you either need to pay cash or sign a decline of treatment. I would generally inform you that it might be wise to contact them yourself (as if you hadn’t already thought of that right) like clockwork – every patient that fits into this example will call me back and tell me (usually in a very angry tone of voice-understandably) that they were told by Fred X. that no one by that name works there and the services are covered they just need review by the Utilization department. This goes on sometimes around 2 or 3 times before a concrete written decision is made. The punch line – not one insurance company out there will ever authorize, pre-certify or pre-determine services without a disclaimer just before you hang up that says ‘this is not a guarantee of payment…’ But when you put the word ‘authorized’ in big bold writing – that is obviously the assumption of the patient.
c. Health Maintenance Organizations (HMO)
It saddens me to start off by saying, that up to 40% of the patients who come into our office every single day are completely unaware that they had an HMO and they even handed us the card; they thought they had Medicare/ Medical (medi/medi) but low and behold they signed the contract with the provisions and yet they are somehow oblivious.
I won’t say they are evil because that would be slander, and I won’t tell you not to join them – because that may also be construed as such. What I will say is this; I would highly recommend that you read that contract YOURSELF as many times as you need to, to understand what it means before your mind is made.
Part I. How it works
An HMO is much different than a PPO type insurance (also EPO, POS, etc.) in that; you may not self refer to anyone, responsibility for your general well being is almost always belongs to your PCP, all services are contracted to a specific doctor or facility and you receive services from that facility/provider only. Second opinions are considered on a case by case basis (this can take months), and rarely they will ok you to go out of network if for a very special reason your care could not be facilitated with an in network provider - they don’t tell you the real reason for their scrutiny because they don’t want you to know a few things.
- You go to your PCP (primary care physician) first - always
- Based on clinical info or tests he/she orders makes a diagnosis
- If it requires surgery or other measures he refers you to the specialist that your HMO is contracted with
- Specialist consults you and gives his opinion to the PCP
- Your PCP submits the recommended treatment to your HMO for authorization
- (if they approve it) You are treated and sent back to your PCP
On the outside, it all seems a tad more complex than just setting an appointment with whichever doctor you chose but not overbearingly so.
The structure of an HMO can be extremely complex but when you get through all the IPA’s and insurance carriers and you find out which HMO you are talking about (and I have never heard a patient who was actually able to tell me which HMO they were contracted with) they are fundamentally the same.
At the top you have the medical director, the final decision maker; they are making the big bucks and every piece of care he can reasonably deny without violating his contracts is money in the bank to him or her. The medical director is generally a licensed medical doctor, some still practice medicine in a clinical setting – but we will get to that later. Directly underneath the medical director you have the Utilization Review (or utilization management) department which is comprised of some nurses (administrative nurses not the kind that work in the E.R. etc.) and other licensed medical professionals who are there to do the simple reviews that are clearly defined by the medical policies. The reviewing nurses usually have say over the lower level review staff, if one of the people who answers the phone in this department and can’t answer your question they are generally putting you on hold to ask their nurses who will in turn review the guidelines of your HMO and make a decision.
Health Maintenance Organizations (HMO’s) contract with specific physicians, or facilities for certain services – if they can they will capitate the services which means that the provider under capitation does NOT get paid for each patient; a provider who is under a capitation consults and treats up to XXX hundred patients a month (through the given HMO) for whatever capitated services they are contracted to provide for a monthly check set at $XX,XXX. Meaning that whether he/she see’s you one time or 5 times and does a major surgery he/she still only gets his/her set pay. Only after he/she saw more than however many hundreds of patients his/her capitation permits would they get paid any extra money.
Part II. How it affects patients' care
What if I was to tell you that – if you are enrolled in an HMO there is a chance that the medical director of your HMO could potentially be an employee of your PCP or vice versa? As in your PCP - Doctor A could work for Doctor B who owns their group practice and Doctor B also could happen to own the HMO they are both contracted under? That sounds really confusing but if you can understand it – it is a huge problem.
Example:
Patient: Tom
Patients Primary Care Physician (PCP): Dr. Two
Patients HMO: XPLAN
XPLAN ‘s Medical Director: Dr. One
Dr. One has owned his practice comprising of himself, Dr. Two and several other doctors who specialize in Internal Medicine for XXX years. Dr. Two and the other physicians are legally employed by Dr. One. Tom has a pancreatic mass discovered by Dr. Two on an MRI. Dr. Two asks Dr. One what to do; Dr. One wants it removed by a surgeon – he refers to the contracted surgeon. The surgeon says it is not something that can be performed at the community hospitals he goes to – that you would need treatment at a university hospital (or other special setting facility). He sends his recommendation back to Dr. Two who submits to XPLAN for authorization – XPLAN is not contracted with any specialized facilities of the sort; therefore it is considered an out of network expenditure which must be reviewed by the medical director Dr. One. Dr. One decides he is safe denying the service as not contracted and out of network because the plan has not contract with the other facility and therefore it would be an ‘unjustifiable’ expenditure.
Some other problems that HMO’s have:
- PCP’s are held more accountable for following up on things like breast masses. This makes them more subject to penalties if they were to miss anything therefore if you have an ultra-sound or mammogram report that even says something as vague as ‘incomplete study; further workup needed’ many PCP’s will automatically send you to a surgeon ASAP without telling you anything specific. Some of them even make it standard policy to send directly to a surgeon anytime you have screening exams for breast masses – regardless of the results. For the majority of patients who were referred haphazardly and without justification, this turns out to be a waste of the patient’s time and they can’t help but be honestly frightened to tears when their regular doctor sent them ASAP to a surgeon without giving them any details: and to top that off they really can’t handle it if they have a surgeon tell them the results were normal. Their argument is valid – why was I referred if results were normal? From a professional standpoint this is a catch 22 for a surgeon because he/she will hurt their business reputation if the honest answer is given – that their primary doctor didn’t want to be responsible for it.
- Patients who are not familiar with the way things with work in an HMO are often very angry when they find out they have to wait for authorizations, can’t be seen without a referral and all the other hassles that come along with the HMO they signed up for. These people offered me a plan, told me it offered 100% coverage, they didn’t say anything about referrals and doctors being in network or capitated services, I’ve never heard of such nonsense in my life! Why do you think they omitted those minor details? They also probably left out your co-pay and the reduced coverage if you use out-of-network providers too.
- By the time a patient gets to a specialists office, they don’t expect to have to consult the doctor. The patient has waited 2 weeks for the appointment, what do you mean you’re not taking out his gall bladder in the office? He has to wait another 2 weeks for the surgery to be authorized and scheduled? Yes I am afraid that is how it works; you can’t bill a surgery without a matching consult/history and physical – unless you go through the E.R. which would cost you way more money. But even if you do that, the hospitalist on call for your HMO would probably just send you home and try to have it handled outpatient to save the HMO money so he/she didn’t get your E.R. visit carved out of his capitated rate.
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You thought your healthcare was based on what you needed to be healthy? It should be, but sadly sometimes it isn’t. In case you are wondering, yes I have seen a situation closely resembling this happen. I am forced to omit specific details due to confidentiality and the fact that I could lose my job if I were to release names and so on.
I will be expanding upon my argument in the next post on healthcare; hospitals! But my hands are tired for now. I hope any readers can take this information for what it is worth. Again these are my observances, experiences, and opinions – as seen from behind the scenes working for physicians, all of whom I must add are skilled, talented, and fundamentally understand and most certainly abide by the oaths they all took.
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