This week I had an interesting situation with a patient and his insurance company. A young man with a mass in his nose that clearly needed surgery. As usual we called the insurance company first to get pre-certification. This informs them of my plan and whether I can proceed with the proposed treatment. Since they are paying they require us to obtain their permission and that’s fine. One would think that if they approved the surgery that would mean I would get paid, but that is not the case. They approve the surgery and then decide afterwards whether his benefits apply. For this patient I was told by the insurance company that his condition is pre-existing and so I can proceed with the surgery and then afterwards they will decide if they will pay. It’s not like if they don’t pay me I can take the surgery back.
Thereafter, I spoke with the patient and told him if he wants to proceed he would have to pay us in advance for the surgery. If his insurance company paid us we would refund his money. I they denied our claim we would keep the deposit. As of now he has refused to agree to those terms and is looking for another doctor to operate on him and will do so knowing he or she may not get paid, but will only know that after the fact.
As a doctor why do I have to deal with these insurance company tactics? I wasn’t trained to negotiate with a bunch of bean counter suits whose only goal is to find ways not to pay valid claims. This is another example of a patient being failed by his insurance company. It also demonstrates the shortcomings of the current proposals as well as the problems with for profit private health insurance.
The administration is putting forward the notion that an insurance company cannot deny coverage to anyone, an obligation that already exists in
The solution is to mandate coverage for everyone at all times so there will never be a gap in coverage that can result in denial of services. This makes sense because often illness comes on unexpectedly so one should always carry health coverage. But logistically how can you force the small business owner or the fellow who just lost his job to pony up thousands of dollars that he/she may not have for a private plan? The only answer I can come up with is for government to step in. As much as it bothers me, I agree with the need for a public plan as a safety net for those who need to fill in their gaps in coverage. This coverage must be bare bones in order to minimize cost to the taxpayer and to incentivize the individual to obtain a better private plan.
A 4:59 a.m. post? Is that the correct time? How does a public option help someone who already has insurance through their company? Doesn't it benefit only those who are not covered by insurance today or those wishing to switch.
ReplyDeleteLooks like the House version of the bill has the following regarding pre-existing conditions - "Insurance industry practices such as denying coverage on the basis of pre-existing medical conditions would be banned, and insurers would no longer be able to charge higher premiums on the basis of gender or medical history. In a further slap, the industry would lose its exemption from federal antitrust restrictions on price fixing and market allocation".
ReplyDeleteIf that is the case that a company must accept patients with pre-existing conditions and cannot raise thier rates the business model is no longer profitable. This will definitely result in the demise of the private insurance business resulting in the government being the sole payer which is the dems goal all along.
ReplyDeleteHere is what I could pick up by the CBO. It requires further analysis and more detail related to pre-existing condition. the senate is waiting for the CBO to provide cost estimates on their plan. "The Congressional Budget Office (CBO) estimates the total cost of the House plan at $1.055 trillion over a decade, with a net cost of $894 billion after taking into account certain revenues.
ReplyDeleteThe CBO also projects that the bill would lower the federal deficit by $104 billion by 2019. These savings would come mainly through deep cuts to federal programs, particularly to Medicare. The bill also includes a mandate that individuals and families obtain insurance or pay a penalty, guaranteeing that billions of dollars are funneled to the insurance companies in the form of new, cash-paying customers.
The legislation includes a watered-down version of a “public option” available for purchase alongside private insurance plans on an insurance exchange. Unlike under Medicare, where the government sets rates for payments to health care providers, the secretary of health and human services would have to negotiate rates for payments to hospitals and doctors".
There is a research paper done for the CBO entitled Private Health Insurance Provisions of HR 3962- here is qoute #1:
ReplyDeleteFor example, H.R. 3962 includes a number of provisions to alter how current private health insurance markets function,primarily for individuals who purchase coverage directly from an insurer or through a small employer. H.R. 3962 would require that insurers not exclude potential enrollees or charge them
premiums based on pre-existing health conditions. In a system where individuals voluntarily choose whether to obtain health insurance, however, individuals may choose to enroll only when they become sick, known as “adverse selection,” which can lead to higher premiums and greater uninsurance. When permitted, insurers often guard against adverse selection by adopting policies such as excluding preexisting conditions. If reform eliminates many of the tools insurers use to guard against adverse selection then, instead, America’s Health Insurance Plans (AHIP), the association that represents health insurers, has stated that individuals must be required to purchase
coverage, so that not just the sick enroll.4