Affordable How?

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“Moving on… Here is the list of ACA plans we will be taking.” My office manager directed everyone to page thirteen of the meeting packet.

Groans from the staff.

“We have been told by corporate that we cannot ask if someone is in the three month grace period or if they are paying their premiums. We have to see them, though, even if they have not been paying their premiums. If they have not paid their premiums after the three months, the insurance company will drop them and demand that we refund the money they paid us.”

“Wait.” I leaned forward. “They don’t go after the patient? They go after us to get the money back?”

“Yes.”

“So then we have to get our money back from the patient?”

“Yes.”

“Like that is going to happen.” I sat back and crossed my arms across my chest and squinted at her. “Is this really true?”

“Yes.”

After the meeting, I pulled her aside.

“How can the government do this and expect physicians to sign up for these plans? We are taking tremendous financial risks, then. Most of these people need to get caught up on immunizations, preventive care labs… hundreds of dollars worth of stuff. We can’t do it right out of the box, then. They will have to come back in three months. But then that makes us take a hit on our preventive care numbers.”

“I know.” My office manager was trying to keep her impassive face in place. “But this is what legal is telling us.”

Truthfully, I was hearing that other physicians were calling to verify insurance premium payments but were having great difficulty getting that done since it was requiring upwards of an hour on hold to get the info for each patient. No one has the staff for that kind of thing.

“Is this just one of those overly cautious, let’s not even remotely maybe get into trouble interpretations that legal is known for? Or is it for real?”

“That I don’t know.”

And we still don’t know. Not for sure.

I don’t have time to read 11,000 pages of legislation, nor do I have any idea who to ask. There are plenty of ways to help patients “navigate” the system. Not so much for physicians. So I have to follow the guidelines that have been handed down through legal and cross my fingers.

The fact is, my office, and thousands like mine, are not rolling in the overwhelming bounty of the medical cash cow. I have a 50% overhead. Our practice currently has over $150,000 that has not been paid to us over the past year, much of which will never be paid by the patients who owe it. We run a tight ship. Primary care is like that.

But the money issue isn’t the most upsetting part. It is the not knowing. Not knowing who or what to ask. Not knowing if I have been given the right information or if that information has changed. Waiting. Waiting to see if we are going to take a hit.

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89 thoughts on “Affordable How?

  1. Wow the bureaucratic BS! Wouldn’t that also make you the bad guy to your patients? The very people you’re trying to build a trust with? Sounds like the Ins. companies or whom ever made this crazy rule are a bunch of cowards.

    Liked by 3 people

    • Still a risk financially, though it is less. There is still the issue of preventive care scores and delay of treatment. The patient that comes in for sever abdominal pain on their first visit. There are just things I HAVE to do.

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  2. Whoa. Just…whoa. This is part of the ACA that I had not heard of. That is freakin’ ridiculous to expect physicians to take on that kind of risk. From Day 1 there was speculation about how many of the sign-ups would result in actual premium payment. I can’t believe you can’t check! (I’m not doubting the truth of what you are saying, just…whaaaaat?) I **can** believe extremely long waiting times to verify.

    When I was working the phone and web chat for Healthcare.gov, this is something that would come up time and again and there were NO answers, “Where do the physicians go for help?” The consumers had the regular exchanges. Small businesses have their own exchange. But the doctors?

    Gah! “We” hate the insurance companies.

    Liked by 3 people

    • Yeah. I doubt the validity of not being able to check. BUT regardless making physicians bear the brunt of the financial responsibility is stupid. There should be no “grace” period. You either have it or you don’t have it. Don’t stick it to the docs.

      Liked by 3 people

  3. That doesn’t sound fair. You aren’t allowed to ask questions before you provide a service that you may never be compensated for? And, if you do provide a service and someone else is “not responsible,” you have to surrender your compensation for services that can’t be taken back? As if that happens in any other industry. And, what stops patients from jumping between insurance companies every three months – getting covered for health services and screwing over physicians. Sounds to me like this could be the beginning of a “physicians leaving the U.S.,” much like what happened in Canada when everyone thought that opportunity was better south of the border.

    Liked by 2 people

  4. In the first decade of 2000 we have the Wall Street mess screwing the American public,
    now we have the insurance companys screwing the American public. Thank you, elected officials!

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      • You know I was thinking abut this and I can see why they do it – and there’s not much chance that it will change. That being said – there are a number of similar systems in other areas that have found solutions. For instance with dentists, they verify the coverage either before or imediately after the sevices rendered – by using a modem link to the insurance provider. The other similar system is in transportaion – we were always required to verify employees’ driver’s iicences before allowing them to drive our equipment – so the Ministry set up an on-line site that allowed verification of licence in a few seconds. I think you need an electronic verification system of some sort.

        Liked by 1 person

      • We have one. We use that for all non-ACA insurances (see, you’re brilliant!) BUT it does not show the grace period for most of the ACA plans (at least as far as I know). Either #1 do away with the grace period (this is my favorite), #2 take away the punishment of physicians, or #3 make online verification specify grace period or not.

        Liked by 1 person

  5. This is exactly what you can expect when you mix government and medical insurance. [Disclaimer: it has been a few years since I have had anything to do with processing insurance claims for doctors (well before ACA) and my memory isn’t what it used to be, but the information I’m about to convey is true and unexaggerated.]

    I had a client (a psychiatrist) a few years ago that took every insurance out there, including a few Medicaid patients. At one point we got a letter from the state Medicaid office questioning his coding for three services for a patient. The claims were three years old and had been paid already. The CPT codes (the numbers that tell the insurance companies exactly what service was performed) had since changed. The company retroactively denied the claims because we used the wrong coding (ie, we used the coding that was in effect at the time of the filing, but they wanted us to use the coding that had replaced it later — coding that didn’t exist when the claim was filed). I argued, I pleaded, I even went so far as to re-file using the new coding. They denied everything. Why? Because we were past the “one year” filing date of the original service. Instead of asking for a refund check, they simple confiscated the checks for services recently rendered.

    The doctor decided it wasn’t worth a lawyer and said to forget it. Six months later, every single patient claim we had made in the year before the CPT code change was denied, and the money scooped up from current patient services. We were out about six grand before we could go through the hoops to cancel our Medicaid contract and refer our patients to other doctors. And it still wasn’t nearly what it would have cost us to fight it in court.

    This was just one office that only saw a few Medicaid patients. I hate to think how this scam affected other Texas physicians bottom line.

    Liked by 3 people

      • By the time I retired it had gotten to the point where it all was too risky to take (IMHO). When I retired, none of my clients were taking any form of insurance at all. But in each case, the first thing they all dropped was Medicare. Not because of the crazy-low payment schedule, but because of the Catch-22 rules. The final straw for one doctor was when he was notified that he’d treated a person who had Medicare, The patient had filed our bill with them, but after the one-year filing limit. The claim was denied for being late. Then Medicare contacted us and stated that (a) we owed the patient a refund of all monies paid for that year of treatment. We had a signed statement from the patient that they didn’t have Medicare. I brought this up with the Medicare rep who read me the “rule” over the phone. Bottom line: if the patient has Medicare, the doctor is responsible for filing it and cannot charge the patient anything over their pay schedule (which is zero for denied claims). It doesn’t matter if the patient lies about having Medicare. It’s still the doctor’s responsibility.

        Oh, and (b) if it happened again, we ran the risk of being investigated and fined (the fine at that time was $25,000 per line item). Is it any wonder the doctor opted out of Medicare? [Which, BTW, he has to re-do every 24 months or the government puts him back in again…]

        Liked by 2 people

  6. Sounds like the insurance companies are delegating a job they would traditionally do onto you on the medical side. Lazy or smart depending on which side of the fence you are standing on. If no one questions then the job will remain yours. But the question you raise is who do you complain to.

    Liked by 1 person

  7. I can’t imagine dealing in a system like this. Why were people fighting tooth and nail over the ACA? It sounds pretty much like business as usual. How is it people accept a system like this? Could doctors get organized and really fight this?

    Liked by 1 person

  8. “But this is what legal is telling us.” I am a bit sick of the way we refer to corporations and ‘Legal’ as a person that is of a higher species that has no conscience. ‘Legal” is actually a group of real people who just don’t seem to have an empathetic neuron in their head.

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  9. “But 4.5 million uninsured got coverage!!!!” *Rolls eyes* I’m waiting to see how long till it all explodes. This healthcare debt is a giant soap bubble that unfortunately will burst- but who will pay for it? Not the insurance companies. Not the drug companies. Not Corporations. It will come out of normal practitioners salaries and payments, or the tax dollars of the middle class. >: (

    Liked by 1 person

    • Part of the appeal of a single payor system would be taking it out of the hands of the insurance industry. Of course that gives the power to someone else. Truthfully no one will ever be 100% happy about anything no matter what is done.

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  10. The price of politics. It didn’t have to be this way, but the political opposition to fixing what was clearly a badly broken health care system was so strong that what came out of the doughnut maker was not what anyone really wanted or anticipated when the raw dough went in. Sorry it’s causing you such grief.

    Liked by 2 people

  11. The patients don’t know either…seriously. NY State used to have a good system for medical insurance for self-employed people or those who had lost their jobs or insurance for some reason. It was easy to enroll and simple to understand. But they discontinued it because of the new insurance law. My doctors couldn’t tell me what insurance they were currently taking, let alone what they would take from the new plans! So choosing a plan (which was stupidly time-consuming and frustrating) was done blindly by me. Here’s my question: why don’t doctors unite and tell Congress what would work for them? Why don’t they propose something?

    Liked by 1 person

    • Good questions that I do not have much of an answer for. Doctors are super busy. Politics is time consuming. We like to be autonomous and in control. Our professional organizations are failing us, I think.

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      • True for all our professions I’m afraid. I have to admit I wrote many letters to politicians at all levels about the health care bill, what I wanted to see and did not like, what my experience with it was, but never got more than a generic “thank you for contacting us” reply from anyone. They do wear you down that way. It’s easy to say, “why bother?” On the other hand, doctors have at least some respect, unlike patients…they might listen. (or not).

        Liked by 1 person

  12. Where do you find the time or emotional energy to deal with all this ? So sorry for you. Glad to see the view from the other side. We signed up for ACA when my husband lost his job of 40 years. No real problems so far. I guess we are some of the lucky ones.

    Liked by 1 person

    • I think the ACA has helped people. How much depends on the region. It is staggering how much it varies between states. The program should not be scrapped but it certainly needs to change in some key areas, like this one. Rather than pitting physicians against patients and patients against physicians, it should strengthen the relationship. We are all on the same team.

      Liked by 1 person

  13. Things like this and the BS that happens in the education system make me want to go live on an island and eat coconuts all day. Maybe bring a few books…my family. A large fishing pole…

    Liked by 2 people

  14. This really sucks. And it shows that we have so much to do to improve things. He, I have had enough experience with insurance companies (and I lived in Hartford!) to know that healthcare is the farthest thing from their collective (and deadly boring) minds.

    Liked by 1 person

  15. Yes, everyone takes a risk, except, you know…the ones that measure the risk. They just take the money.
    Sorry to hear that this is part and parcel of the ACA. Single payer, that’s my story and I’m stickin’ to it.

    Liked by 1 person

      • This is one part of the medical system (well there are a lot ofr parts I don’t understand but…) that makes no sense. How can Medicare/Medicaid be different from place to place? Why isn’t it consistent as far as how medical facilities and practitioners get paid? It is rhetorical really, as I’m sure you don’t want to have to go into that at length. And I don’t understand how a facility or practitioner can say “I’m not participating.” The whole thing is broken from top to bottom, and it is becoming more and more apparent that any kind of permanent improvement will have to be of the entire thing, not just the ACA and its spawn/replicates/substitutions from either camp.

        One thing I never hear anyone say is that we all understand that everyone cannot have hip replacements, multiple open heart surgeries, and every new drug under the sun without someone paying for it. Medical consumer expectations have to be addressed as well, not just the provider/payor issues.

        Ooops, I think I was beginning to rant there.

        Liked by 2 people

      • Medicaid and Medicare don’t vary. It is the other policies that do. If you are in an area with good paying policies available, doctors want to take those. Medicare and Medicaid are terrible, so it is hard for me to imagine private payors being worse but those areas do exist.

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  16. Let me start this way…I have Obama care (or I should say I had Obama care until I was able to secure employment that offered insurance). I lost my primary care physician, whom I have seen for 10 years, because I had Obama care and he wasn’t going to accept ACA plans. My ACA Plan – Humana; My new plan -Humana, now he’ll take me back — guess what, bite me! He didn’t want to stick with me while I had hard times and needed the help of ACA, you’re not going to get me back now. Oh, and by the way in 15 years when I have Medicare (you know that government provided health insurance that we shouldn’t call socialized medicine even though it is PROVIDED to retirees by the government), he can offer to kiss my butt in Times Square, but he’s not getting my Medicare dollar.

    So what I am understanding here is that the Physician’s are concerned about being paid by the ACA if a patient is in the three month grace period for premiums – by the way, if charges are incurred during the three month period and the patient does not pay the premium, the patient is responsible for the full amount of charges. But I ask, which charges, cash rates, their insurance rates, medicare rates? Regardless, responsible none the less.

    The rebuttal? “Then we are responsible for collection of these fees and we’ll never get paid.” Is that any different than a Medicare denial a year from now when they just take the money back and you are left holding the empty bag (well its really not empty since it has been filled by other Medicare Rate receivables), will you go after the 89 year old medicare recipient to pay those charges, or write them off? After all, they did pay their co-payment when they were in the office so its not like you are giving them preferential treatment if you write it off. Oh, I forgot, bill their secondary insurance, they’ll pay something and that’s better than nothing.

    Bottom line, as an ACA covered life, I have been made to feel sub-standard, mistrusted, and shunned by my physician. Personally, I felt great pride in my government for giving me an affordable opportunity to cover me and my family with decent healthcare – instead of using the ER as my Primary Care Physician, or not seeking care at all. There is something to be said for that and I think that needs to be take into consideration before we are judged as deadbeats who don’t pay our bills.

    By the way – I am hardly a deadbeat – I made $95,000.00 last year as a consultant and educator in the medical field, but had no insurance. I used the ACA for as long as I needed and then when I didn’t, moved on to allow others the opportunity to have affordable medical care.

    Liked by 2 people

    • The Humana plans in particular in my area were horrible for finding specialists. I have been yelled at and my staff has been yelled at repeatedly by patients because we could not find a specialist for them within a thirty or forty mile radius of a large urban center. So I have a patient with a cancer and I cannot get them treated? What can I do? I have no choice but to stop taking that insurance. The point with trying to collect from patients with ACA is that I have a difficult time collecting from my insured patients. Many of the people who are using the ACA are on hard times. I have an ethical issue with trying to squeeze blood from a turnip. They are not bad people. Ideally, there would not be a grace period. Cover people if you are going to cover them for crying out loud. That is what I want. Patients to be covered and to have the ability to get seen by the doctor of their choice. A guessing game is not good for doctors but especially not for patients. It drives a wedge between patients and their physicians, eroding what should be a sacred relationship. I am sorry that you have felt discriminated against. That is not your fault.

      Liked by 1 person

  17. My parents have Medicare HMO’s. I have been sharing the content of your posts. They complain less now about the routine calls they get from their physicians to keep a routine schedule for follow-ups. ( She has bouts of A-fib, him – HTN ) Seeing their Mds’ is a good thing!

    Liked by 1 person

  18. Reblogged this on 61chrissterry and commented:
    An interesting post. Here in the UK our NHS is free at point of delivery for those eligible , with costs being borne from Central Government funds from various forms of taxation from the UK population and businesses.
    However, due to the ever increasing costs required by the NHS, many over the years have suggested that some treatments should be paid directly by the recipients who would most likely have to obtain forms of medical insurance to cover their costs.
    By viewing this post, it is more evident that our current means of funding the NHS needs to be maintained.

    Like

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