Wednesday, January 2, 2013

Patients can be clueless about their insurance coverage

Not long ago, I blogged about a plastic surgeon who aggressively pursues patients who refuse to pay her bills. The state is suing her to make her stop and also considering lifting her medical license. You may want to take a look at that post to get the details, but the central theme is that she makes patients who she sees in the ED to sign a form stating that they will pay her. It is unlikely that the patients are aware of the amount of the fee up front. Then she won’t accept what insurance considers a reasonable reimbursement and goes after the patients with lawsuits and liens on their houses, ignoring the fact that balance billing of emergency department patients is illegal in her state.

A number of doctors have defended the surgeon. Many have said that the patient should have asked her what the fee would be. In my experience, that is a rare occurrence. I’ve been a surgeon for four decades and I can’t recall a single patient asking me what the fee for an elective operation would be. I hardly think a patient would ask at the time of an emergency.

Most patients either don’t think about it or don’t consider it an issue. In many cases, they don’t understand how the system works at all. Here's an example.

A new patient arrived for an appointment with the doctor. At the time he called to schedule it, he was told that the doctor did not accept his insurance. At check in, the secretary reminded him of this, and having amnesia for the previous conversation, he was taken aback and said, “I thought everyone had to accept WeDontCare.”

Further questioning revealed he had a $5000 deductible policy and he had not used any of it yet this year. Even if the MD had participated in WeDontCare, the patient was shocked to learn that he would have had to pay for the office visit.

He was then told that the fee for the comprehensive new patient examination would be $250.00. When he balked at this, the nurse asked him why he chose such a high deductible policy if he didn’t want to pay for visits out of pocket. He said it was because the premium was so much lower.

The nurse explained that the point of a high deductible policy was that in exchange for the lower premium, he accepted the risk that some or all of the money saved might have to go toward paying for medical care, probably a reasonable risk for someone in good health. He didn’t seem to understand that unless he paid out of pocket for more than $5000 (less what the lower premium cost was) worth of medical care in a year, he was ahead of the game.

The patient then began to see the light. If this man, who was a retired financier, had never thought this through, how would anyone expect the average patient to do so?


artiger said...

Before I became employed two and a half years ago, I would have loved to have had this piece posted in my office.

When it comes to "surprises" with coverage, it is unforunate that the patient's ire is often directed at the physician's office and/or the hospital. The patient should be partly to blame for not being familiar with what he/she purchased (would it make sense to buy groceries without knowing some details about specific items, or worse yet, a car or a house?), but I feel the real culprits here are the insurance agents who sell these policies. Unless you know the ins and outs of health care, it is difficult to understand a lot of the terminology that is written in a policy. (I've read my own policy, and I can't even tell you 100% of what is covered and to what degree.) Every time I've discussed coverage issues with a patient, I've asked them if they were aware of such things when they signed up, and if their agent went over the details in terms they can understand. You can guess the answer to that.

A lot of people think physicians don't do a good job of taking time to dicuss things with patients and making sure they understand; I think we're not the only ones guilty of such.

Skeptical Scalpel said...

Excellent comments. Great analogy to buying a car or a house.

artiger said...

I just got finished repairing a small ventral hernia. I actually saw the man in the office a little less than a month ago. Normally, I would have done his surgery within a week or two of his office visit, but it was December, and I noticed he had not really had much medical care last year, pretty much just another office visit with a hand surgeon for his Dupuytren's contractures. He told me he thought he might get the hernia repaired in December, then get his hands attended to sometime in the next few months.

It was then that I asked him about his health insurance plan, like how much was his deductible? Did he by chance have one of those high deductible plans? He wasn't sure. He said his wife keeps track of that sort of stuff, but he would check and get back to us in a little while. I told him that if he was looking at several thousand for a deductible (which did turn out to be the case), he might want to put the hernia off a few weeks (like until January).

He didn't understand what I was getting at with all that at first, but when he conferred with his wife, he was extrememly grateful at all the money we had just saved him, and so was his wife when I went to talk to her after the surgery. You can bet that his insurance people wouldn't have advised him like that.

Skeptical Scalpel said...

You are correct. First of all, they would have had trouble reaching a human to talk to at their insurance company. If they were fortunate enough to have navigated the automated prompts and spoken to someone, that person probably would not have known what to tell them.

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