Complaints About Insurance

There has been a lot of talk in the media over the last few years about health insurance companies. Some perspectives offer up health insurance companies as the savior of our bloated health care industry. The insurance companies help hold down costs, innovate cost-saving measures, and drive quality. The news from other quarters suggested that the bloated corporate structures of these very same companies restrain innovation, ration care, and divert money from patient care.

The news also gives doctors a similar treatment. We can simultaneously read articles deriding one hospital that chargers $80 for a tablet of acetaminophen while another article talks about the shortage of primary care doctors driven, in part, because the field doesn't pay enough for them to be able to afford their own medical education. 

I've recently had an experience with an insurance company that really just frosted me. I could rant for some time about what happened. Suffice it to say, sending a claim to this particular insurance company is a bit like throwing a nano-particle into the ocean and hoping to retrieve the particle again ten years later by catching it in a coffee filter. The company engaged in a game of lost-and found with the billing forms. When they reappeared they were diverted to an outside processing company which promised to pay me faster if I accepted less money. When I declined the billing forms were lost again, only to be found after several angry phone calls from myself and my patient.

The final straw was when the patient complained to their employer about the low quality of the health insurance. The company brought the concerns back to the insurance company, which in turn called me asking if I'd be willing to become a provider in their network. I was offered a contracted rate that was significantly below any other insurance company in the area along with an 'array' of benefits including a coupon for discount diet products from a national diet company chain.

That just really frosted me. The lost forms, the promise of 'expidited' payment in return for accepting less than half my normal fee, and then there is the coupon. Really?

So please accept into consideration my experience with this particular health insurance company. It is part of the puzzle of health care reform. It's an important part. I offer you the letter that I sent to this nameless insurance company so you can learn a little bit more of my experience of dealing with insurance.

   

Dear (Health Insurance Company Provider Relations Specialist),

I received your voice mail yesterday. This is actually the second phone call I've gotten from (health insurance company) in the past two weeks--both have asked me if I was interested in becoming a contracted provider with (health insurance company).

In 2010 I declined a contract with (health insurance company) because I found the reimbursement rate for contracted psychologists to be unreasonably low. The quoted figure, $70 per 90806 service, is lower than any other insurance company that I am contracted with. In addition it is less than half my standard fee. 

To put the reimbursement rate that (health insurance company) offers contracted psychologists in context, I pay more than that rate to my hair stylist for a haircut, I pay more money to a licensed massage therapist for a massage, and I pay more money for that for an oil change and regular service at my automobile dealer. I pay close to that amount to fill up my moderate sized vehicle with gas. A reimbursement rate  of $70 isn't sufficient to keep the lights on in my office, let alone compensate me for the significant investment I've made in my education or the significant amount of skills I provide my patients.

Additionally, I've encountered nothing but difficulty with out-of-network business I have had with (insurance company). Billing forms are lost and misdirected by your company, I've encountered scores of unhelpful, knowledgeable, and  rude provider relations representatives, and received constant requests to receive a lower rate of reimbursement in return for "speedy" response to my billing invoices.

The most recent contract I've received from (insurance company) last week came with a list of "discounts" offered to contracted providers. I found that particularly insulting. I'm not interested in receiving coupons for diet centers, discount eye glasses, or any other services. I'm interested in being reasonably compensated for my time, experience, and training. I'm interested in having my billing forms processed promptly and my concerns addressed rapidly. 

I again decline becoming a contracted provider with (health insurance company). It simply does not make good business sense for me to enter into a contract with your company.

Dr. Jason Evan Mihalko

Health Care Reform

I was reading the Globe this morning and came across an article about the Lahey Clinic exploring a merger with Beth Israel.  I have no comment about the hospitals merging. I do have a brief comment (also known as a rant) about one particular quote in the article.

Doctors and hospitals also will be forced to take on more financial risk. If they run over budget in caring for a patient, they can lose money; if they come in under budget, they can turn a profit.

It's nothing new that at for-profit hospitals, the bottom line is making a profit. It concerns me though that at the very basic level of insurance reimbursement, there is going to be another built in pressure whereby medical decisions are driven (in part, at least) by a concern for a profit. As a people, we are prone to making decisions in the short term to safe money that in the long term are devastatingly expensive.

Some insurance companies have become so broken as companies that they are nearly non-functional. These non-functional corporate entities are going to be driving health care decisions? Really?

Let's not be penny wise and pound foolish.

Job Killing Health Care Bill: Claptrap Bill?

So with the recent vote in the House on the "Repealing the Job-Killing Health Care Law Act" has gotten the newswire and twitter all atwitter in our usual polarized mess. Many republicans are all fired up that they are going to single handedly save our economy with the passage of this bill. Democrats are all fired up saying that the republicans are placing senior citizens and middle-class Americans at risk with the repeal.


Being a close watcher of the health care reform, I've been trying to poke behind the headlines and polarization. Here is my question. Anyone reading feel free to answer. Just how exactly is the health care reform act killing jobs? I've heard that said, oh, I don't know, a million times. What I haven't seen is any credible information that supports that claim. Without it, I'm sorry to say that the "Repealing the Job-Killing Health Care Law Act" is nothing more than claptrap--empty language.


Thoughts? Anyone?

Friday News Roundup

When and How Health Care Reform Will Affect You?


The American Medial News provided a helpful time line listing when the various provisions of the new health care reform law will go into effect. Do dig deeper, following the link above. To dig even deeper, follow this link or this link. If you still want to know even more, check out this article in the Christian Science Monitor. They  have a nine part series of articles called Health care reform bill 101.


This is a complicated discussion and there is a lot to learn. The facts about this law don't lend themselves well to 140 twitter characters or a sound bite on CNN, MSNBC, or Fox News.


Immediately

• Offers tax credits to small businesses that offer health coverage.
• Starts to close the Medicare drug benefit's coverage gap to eliminate it by 2020.
• Authorizes the creation of a 15-member Medicare Independent Payment Advisory Board to extend Medicare's solvency, lower health care costs and improve health outcomes.
• Extends the Medicare Physician Quality Reporting Initiative through 2014, establishing a physician appeals process and penalizing nonreporting doctors starting in 2015.
• Authorizes the Food and Drug Administration to create a pathway for approval of biosimilar versions of biologic drugs.
• Extends the Medicare work geographic practice cost index floor through 2010.
• Provides funding for the practice expense geographic practice cost index floor for 2010 and 2011.

90 days after enactment (June 2010)

• Creates a temporary high-risk pool for Americans who are uninsured due to a preexisting condition.

6 months after enactment (September 2010)

• Prohibits health plans from canceling coverage for people who get sick and placing lifetime caps on benefits.
• Tightens restrictions on annual coverage limits.
• Extends health insurance eligibility for dependents to age 26.

By the end of 2010

• Begins greater investments in primary care physician training and community health centers.
• Prohibits physician-owned hospitals without a Medicare provider agreement from participating in the program.

2011

• Eliminates co-pays and deductibles for Medicare preventive care.
• Requires individual and small group health plans to spend at least 80% of premiums on health care; increases the floor to 85% for large group plans.
• Creates a long-term-care insurance program for adults with disabilities.
• Provides a 10% Medicare pay bonus from 2011 to 2015 for certain primary care and major surgical procedures in health professional shortage areas.

2014

• Prohibits health plans from denying coverage to anyone with a preexisting condition.
• Expands Medicaid eligibility nationwide to 133% of the federal poverty level.
• Directs the Dept. of Health and Human Services to create health insurance exchanges in states that have none.
• Establishes government subsidies for people earning between 133% and 400% of poverty to buy coverage through exchanges.
• Requires individuals to have a minimum level of coverage or pay penalties.
• Requires all but small employers whose workers enroll in exchange plans to help pay for the coverage.
• Begins reducing federal funding to safety net hospitals for the care of low-income people.

2015

• Allows recommendations of the Medicare Independent Payment Advisory Board to start taking effect unless overridden by supermajorities in both houses of Congress.

What Health Care Reform Means to You

Over the coming hours, days, weeks, and months there will no doubt be a great deal of discussion about the heath care reform legislation that was passed the the U.S. House of Representatives late last night. Here are the important points: (source)


If You Are Uninsured:

• This shouldn't affect those of us here in Massachusetts as by law, we are all already required to have health insurance. 
• Starting in 2014, those without insurance will face a penalty of $95 or 1 percent of income, whichever is greater. That penalty will rise over time, reaching $695 or 2 percent of income, whichever is greater. If you earn less that the income-tax filing threshold, you will not owe anything. If you cannot purchase a policy that is less than 8 percent of your income, you also will not owe anything. 
• More lower-income individuals under the age of 65 will be covered by Medicaid. A family of four that makes under $29, 327 would be covered.
• There will be state-run insurance exchanges. If your income is more than 133 percent of the poverty level but less than 400 percent (e.g., $29, 32 to $88,200 for a family of four) you will be eligible for health insurance subsidies through this program.
• Your premium for thee exchanges would be capped at a percentage of your income ranging from 3 percent to as much as 9.5 percent.
• If you lose lose your job, quit your job, or decide to start your own business you will be able to move between employer-related insurance to insurance from the exchange.

Those with Insurance:

• Your coverage is unlikely to change, though there will be benefits for you.
• No one will be able to be denied coverage based on pre-existing conditions on all policies after 2014.
• If you have Medicare, the "donut hole" will be eliminated by 2020. Starting immediately, those who hit the "donut hole" will get a $250 rebate. Starting in 2011, they will receive a 50% discount on brand named drugs.
• Dependent children can be covered by their parent's insurance until they reach 26 years old, regardless of their school status.
• Insurance plans that have total premiums of more than $10,200 for singles and $27,500 for families would be subject to a 40 percent tax on the excess premium. The taxes would be levied on the insurer, though that price is likely to be passed on to the consumer.

Health Insurance Reform

After spending nearly two frustrated hours on the phone this past Monday with an insurance company I came to an important realization. Those who don't support health insurance reform clearly have not ever contacted a health insurance company.

Here is the short story. Pay close attention as it's confusing. Insurance company A sent a claim to their subcontractor (company B) . Company B contacted me and left a voice mail. I called back five times and never got a return call. On the sixth call they told me the person I was calling was no longer with company B. They informed me the claim was closed and sent back to company A because company B only deals with in-network insurance claims and I am an out of network provider. I would have to contact company A.  Company A told me that I should have never called company B. I actually needed to call company C. A provided me the number for company C. I called that number to find out that it was disconnected. Back on the phone to company A. This time A told me that I should have never been given the number to company C. A asked me to call B and get documentation. B previously said I needed to call A as B could give me no documentation.  A offered to re-submit the claim, telling me that A's adjusters would again send the claim to B. B would again reject the claim and send it back to A because B isn't supposed to deal with my claims. Company A told me that was all they could do.

Sound crazy? That's because it is crazy.

I then engaged in my own version of a filibuster and refuse to stop talking until the provider relations representative for company A transfers me to a supervisor. Supervisor apologizes for any inconvenience and promises to solve the problem and call back by 11 am on Tuesday.

It's Wednesday now and I'm still waiting by the phone with baited breath.

I'm sufficiently motivated to write a more detailed letter to my senator, congressional representative, and the Commonwealth's Insurance Commission. Are you? Have you spoken up about the problems you have encountered with your health insurance?

Contact your elected representatives in congress to complain. Share your story here if you'd like.

The Nuts and Bolts: Using Your Insurance for Mental Health Services

It seems that every time January comes around I spend an increased time on the phone with insurance companies. This year is proving to be no different. People's policies change, employers don't always provide clear information, and confusion ensues.

This might be a good time to take a bit of time out to do a little self-education about your own insurance plan. I've put together a list of questions to ask your insurance company. You can find that on my website, here. Additionally, I have made a glossary of insurance terms. It's helpful when you are trying to decode what it is you are reading when you receive an EOB (explanation of benefits) or are on the phone with your insurance company. Check out that glossary here.

Lastly, I've come across a helpful posting about health insurance that I thought I would share. This link will take you to it: The Nuts and Bolts: Using Your Insurance for Mental Health Services

Parity Law Part Two

Yes, another week has gone by and the Irreverent Psychologist is still thinking about mental health parity laws. I'm still contacting insurance companies here in Massachusetts trying to get an articulation how the law is going to be implemented.

To read the actual law, go here.

A recent study reviewed the successes and failures of the California parity law during the 2000 to 2005 time period. Among the findings:

• Costs of parity were in line or below the projections.
• Most health plans lifted limits on the annual number of days allowed for both inpatient treatments and the number of visits allowed for outpatient treatment.
• Concerns were raised that insurance companies might use the medical necessity clauses to control costs in an arbitrary way.
• Consumers had difficulty finding therapists from individuals who were contracted with the specific insurance company.
• Doctors expressed concern that treatment would no longer be paid for if a patient improved an no longer met the criteria for a particular diagnosis: even if stopping therapy would was not in the best interest of the patient. 

To read more about this study go to the LA Times blog or the abstract of the article.

Wellstone-Domenici Mental Health Parity Act

Mental Health Parity is coming to a health insurance plan near you on January 1st, 2010. The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (commonly known as the Wellstone-Domenici Parity Act) was enacted into law on October 3, 2008. After a long lag time, most insurance plans are required to be in compliance with this law by the first day of the new year.

This bill is designed to end the health insurance benefit inequity between mental health/substance use disorders and medical benefits for group health plans with more than 50 employees. This means that there cannot be arbitrary limits for the coverage of biologically based conditions (e.g., 12 sessions a year for the treatment of depression if there are no similar limits for medical visits).

It is estimated that under this law, 113 million people will have the right to non-discriminatory mental health coverage.

Massachusetts has had a parity law for sometime. However, under this law individuals who are enrolled in self-funded plans (fully funded by the employer) were not covered by the parity law in the Commonwealth. This is changing on January 1st, 2010.

There are some important caveats. Mental health and addictions coverage is not mandated. No insurance plan is required to offer this type of coverage. Mental health coverage is offered at the discretion. An employer can elect to purchase a plan that offers no benefit at all. Additionally, companies with less than 50 employees are not required to provide parity. Lastly, there is a cost exemption. If, after six months of meeting the requirements of this law, a company can demonstrate and have certified by a licensed actuary that the costs of providing this coverage are excessive, their group health plan can be exempted. Excessive is defined as an increase of the actual total costs of coverage by two percent during the first year or one percent in subsequent years.

For more information:

Mental Health Parity Summary

Have a complaint about your insurance plan?

Commonwealth of Massachusetts, Division of Insurance