It was not exactly her chief complaint, but it was one of the concerns raised by my patient at a recent office visit. In fact, it has become increasingly more common in recent years for patients to raise concerns about their insurance directly to me, their doctor. Not only is dealing with insurance companies a time-sucking administrative burden for practices and a an endless source of frustration and illness-inducing stress for patients, this nuisance has now found its way into the exam room. I have literally started a pen-and-paper list where I log the ridiculous anecdotes from my patients, details of how insurances carriers rejected claims and the alleged rationale. I have come to refer to these various tactics as "the bag of tricks." They seem to occur in waves, then die down for yet another new trick to emerge while the old trick shows up from another carrier as its success ripples through the Interpol-like covert communication between the players of the oligopoly.
I'll share a few examples. A patient of mine needed an outpatient surgical procedure for a precancerous condition. Being a conscientious member, she called her health insurance carrier to verify outpatient surgical benefits. She confirmed that both myself and the outpatient surgical facility were in network, but the hospital's lab and pathology department were not. Her in network pathology group was.....in another state. Did they want her to drive her surgical specimen across state lines? That sounds cost effective. Let's hope there is a nearby in-network hospital to treat her post-op dvt (blood clot) while she is there handing off her specimen.
Another patient, also undergoing outpatient surgery for a non-emergent but very time-sensitive and potentially emergent condition, received notification from the anesthesia group after her surgery that they were not in network with her insurance, despite the fact that the facility was approved, and were initiating the burdensome appeal process.
Yet another patient was told by her insurance company that every time she goes for inpatient or outpatient procedure or evaluation she needs to call and verify the facility, the treating doctor, the lab, the anesthesia group, the pathology department, etc. And, then what? Hire her own anesthesiologist while she is on the way to the hospital just in case her emergency becomes surgical? How is she supposed to know or accomplish this?
Which brings me to another example. I have not experienced this one directly, but have had colleagues who have seen claims denied by insurance companies based on place of service noting that for the diagnosis rendered, the patient should have been seen in the emergency department OR should not have gone to the emergency department. So now, not only do patients need to be hiring their own anesthesiologists and pathologists, they also need to know their diagnosis and its exact acuity before arriving. Isn't that why they come to us?
My most recent entry to the bag-of-tricks log, so ridiculous as to be almost unbelievable, comes from a patient I was seeing for her annual well woman exam. She had elected to switch birth control methods at her previous visit, so I inquired how she was doing with the new method. She had never started it, because her carrier denied payment based on having her designated as "male" gender. Never mind that she is one of those rare patients who hasn't changed her insurance plan in over 5 years, and that they covered the previous contraceptive. But, honest mistake, just a little clerical error when updating the plan year, maybe? She clarified her gender of choice and requested a correction. Apparently, this is an unreasonable request without her furnishing both her birth certificate and her marriage license, documents that she was never required to furnish before. She asked them would they prefer to cover maternity claims? I suspect they would use the same clever trick to deny and/or delay payment of those claims as well. In the mean-time, with her money and the money of doctors/pharmacists/facilities they're refusing to pay, they continue to make themselves rich on the arbitrage.
Even more upsetting to me than the bag-of-tricks practice is the evolution of full coverage for screening and full patient-responsibility for diagnostic work-up of any abnormal screens which has become ubiquitous across the typical plan offerings of the oligopoly. A patient has an abnormal pap smear, but does not want to come in for the requisite biopsy because it is subject to the astronomical deductible that she will never meet. Or a screening mammogram was suspicious and the patient declines the diagnostic work-up and biopsy for the same reason. Many patients seem to feel that the diagnostic evaluation is not important and only want to continue with screening that their "insurance pays for" as they put it. Many struggle to understand that a screen is only as useful as its follow through, despite my best attempts to explain. They've become so accustomed to thinking that their insurance dictates their health care that the message they've received is that following up on abnormal screenings is not important, when in reality it can be life-threatening. Having this kind of insurance plan has become a deterrent to following through with appropriate care and a risk factor for advanced disease. It has also become yet another insurance-inducing administrative burden as physicians and their staff spend endless hours calling and sending letters to patients declining important diagnostic evaluations. I think it also bears mentioning here that I, as a self pay patient, paid less for my annual well woman exam, pap smear and screening mammogram combined than I would have spent for just one month's premium with your typical oligopoly plan.
So, what can we as doctors and patients do about this? I will share my strategy. I keep a sheet of paper on my desk with the name and address of my state Commissioner of Insurance and the name and email of the contact on his executive counsel. This information is readily available to anyone who looks for it - search your state, department of insurance. When a patient shares a grievance, or trick, with me, I have them take a screenshot of this piece of paper and I empower them not only to share every detail with this state department, but to let their insurance carrier know that they are doing so. It is amazing how quickly some of these insurmountable errors get corrected when the patients themselves employ this strategy. Looks like we have our own bag-of tricks!
