Health Insurance a Lose:Lose Situation for Consumers and Providers
How did we come to this juncture where we are supporting the lumbering giant that is the insurance industry particularly as it relates to healthcare? I am an NPR person; I listen to NPR when I’m driving in my car and I heard a piece yesterday that really got me upset! They were talking about the rising cost of healthcare insurance. All of the big companies were planning on raising their rates next year and Humana was going to be raising their rates higher than everyone else – like by 40%! It is predicted that for someone earning around 27K, their premium would be about 150$/m. I remember when I earned less than 30K per year, and paying out 150/m for health insurance would have been extremely difficult. So that’s one thing. The other, more important thing that really concerns me – and this, my friends, is the elephant in the room – is how the heck did we get to this place where we support this industry that has absolutely nothing to do with our health?
I have been running my own small healthcare practice for 2 ½ years now. I have been struggling for recognition and compensation from these insurance companies from day 1. Achieving in-network status was the first thing. Cigna updated my new tax ID with my NPI (National Provider Identifier – a national registry that lets them know that the person is legit and bestows a unique identifying number) and we were good to go right away. I thought that all the other companies would do that. But I found out that even though I’d been providing care for their members for nearly a decade, all of the other companies required me to apply for a contract, and most of the big guys denied me initially. Aetna came around after my national body (ACNM – American College of Nurse-Midwives) wrote a letter for me. Humana is just starting to consider a contract – after multiple Humana members applied for a gap exception for coverage for my care. BCBS won’t even talk to me, doesn’t contract with non-MDs and is extremely difficult to deal with – even for their members. The rest of the companies fell somewhere in-between and eventually granted the in-network status.
The next insult is the rates that I am bound to accept now that I have achieved the holy grail of in-network status. My clients pay their premiums and want to use their insurance plan. However, they are subject to their deductibles and co-insurance amounts which require a certain amount of investigation to discover and interpret. The industry standard requires those of us providing maternity care to refrain from billing any services until after the baby is born. This puts all maternity providers in a precarious position because everyone knows that most people are not as keen to pay for a service once the job has been completed. So the trick is to estimate what the insurance company is going to say that the client owes (the deductible and co-insurance up to the amount that is in the insurance contract for the service) and make payment arrangements for this to be paid off prior to their due date. This is irrespective of my charge for the service. If we overestimate, then we have to refund money to the client. If we underestimate, then we have to try to collect for the services that have already been performed.
The Game of Claims and Coding
Submitting forms and getting paid is the other side of this game. The act of submitting a claim is like a ritual or a game – literally. They will deny payment if the coding isn’t correct, but they won’t tell you what’s wrong with it. Most providers pay someone to do this for them and they have to subscribe to a billing platform that electronically submits the claim through one of several national clearinghouses that passes it along to the insurance company. If a paper claim is submitted, it has to be on a particular form that is printed in red ink – if the ink isn’t red, then they won’t accept the claim. And all the while the status of the claim is communicated to the provider through many forms that are generated, printed, and mailed. So much paper! So many people involved who are making an hourly wage!
Keep the Money Between Consumers and Providers
The bottom line is that all of this detracts from the relationship between me and my clients. The longer I participate intimately with this system, the more I am confused as to the purpose of the insurance industry in health care. Instead of paying out large sums of money for insurance premiums to people whose only job is to move paper around (accept or deny claims and issue checks or take-back letters) we could be using that money to pay for health care. Obviously the industry is making money – record gains even – and that is off the backs of their members and their providers. I think those folks ought to find another career and we should move away from this cumbersome system.