Health Magazine

Pay the Patient Says the Carrier, He is the Customer NOT the Doctor

Posted on the 28 November 2012 by Fadi Bejjani @DrFadiBejjani
Insurance Carriers give countless daily hassles to physicians in private practice regarding payment of their services. Of course there is the habitual deductible/co-pay/out-of-pocket/coinsurance saga which can never be ascertained exactly. Then comes the procedure codes: this one does not need authorization this one does and that one depends. Impatiently awaiting the infamous EOB (explanation of benefits) in the mail is like expecting a lottery drawing, except that the latter is more predictable. You may get paid more often in the EOB but how much is always a surprise no matter how precise your pre-determinations and predictions, and denials are galore. To name just of few annoyances: the surgeon may get paid but not the larger facility bill or the whole bill can be rejected because one code out of many is deemed "experimental".  Bottom line, you can never be sure of whether you will get paid and how much. Try running any kind of  business effectively this way.
Appeals are suggested always but they are a joke aimed at creating more useless payment delays and wasting more of your time and staff's time. Every level of appeal takes 60 days and there are several. Unless the patient actively takes his doctor's case at heart and is appreciative of his care, the doctor does not have a prayer with the carrier, especially if he is out-of-network.
In network physicians may get paid faster and easier but the amount is usually puny and non negotiable. Out-of-network physicians suffer most of the guessing game described above. First when the carrier's plan mentions it will pay 70%. that is NOT 70% of what is billed but 70% of what they allow, which is supposably based on "usual and customary". How the latter is determined is still a mystery to me after 30 years of practice.
Perhaps the most frustrating and obnoxious action of the commercial carriers is to pay the patient DIRECTLY when the physician is out-of-network. The patient receives this large check in his name with no W9 or 1099 attached. It is like winning the lottery. Does anyone really think that this patient is going to run to the doctor's office with his check IN THIS ECONOMY and give it to him saying: "Thank you for your services".  This money is all but lost to the practice and also to the IRS since the patient has absolutely no compelling reason to declare that as income. It is as if the carrier is plotting to defraud the IRS of that money! One would think there would be laws preventing this sneaky carrier move. There maybe but nobody cares.
Slavery can be defined as working very hard while somebody else gets paid for your work. How is that different from the out-of-network physician plight?
No-fault carriers are starting to get that way too. They issue checks in both the physician's name and the patient's and now you have to wait for the latter to show up and sign his check so you can deposit it. More hassle more time wasted.
Doctors routinely get paid less than half their bill amounts up to one year later sometimes. In the interim, they provided the care, paid the nurses, clerical staff, supplies, insurance, utilities, rent and others, practically subsidized this patient's care and they have to wait patiently to get paid not knowing how much and when. As I said above, try running any kind of business effectively this way.
It is often that a physician's only recourse is lawyers to arbitrate No-Fault cases, sue commercial carriers under ERISA or sue the patients who kept their checks, If successful these suits will pay a third of what is collected (nowhere near 100%) to the lawyer, exhausting whatever profit left. Furthermore, If the lawyers are too aggressive they could provoke  retaliations in the form of malpractice actions from the patient to defray the money theft, or EUO (examination under oath) from the PIP carrier to annoy the practice and delay further payments, or others. None of that is inherent to the practice of medicine but it was taking more and more of my time and I called it survival.

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