One of the biggest frustrations we have in the health care industry is due to patients not understanding their own health insurance benefits. Oftentimes, patients think that just because they carry insurance, that means that everything is covered and they don’t have to pay anything. Patients receive health care service and a month later they discover that their insurance doesn’t cover that particular service; however, instead of accepting the responsibility of paying, many patients fight, demand, and threaten the physician’s office staff to make the balance go away.
This phenomenon has gotten worse in the past twenty years or so. I subscribe to the theory that much of this mentality is due to the inception of HMO’s. In the beginning, HMO’s had either zero patient financial responsibility, or an exceptionally low out-of-pocket cost. People have been conditioned in thinking that health care is an entitlement. After about a decade, due to insurance companies (and employer groups) not being able to withstand the expense of higher utilization of “free” health care, they began to make the consumer more responsible by charging higher co-pays and not covering certain services. Unfortunately, most Americans expect the same Cadillac coverage without any additional expense (beyond their insurance premium and co-pay).
A major challenge in physician practices is to help their patient’s understand their insurance company’s reimbursement policies, all the while maintaining good will. Physicians are finding themselves having to develop various financial informed consent forms to assure that the patient understands that they may be responsible for some of the cost. Medicare has required this, in the form of Advanced Beneficiary Notices (ABN), for years. Even so, we often hear patients state, “I signed it but didn’t read it.” Or, “I was afraid if I didn’t sign it that I wouldn’t get the service.” Perhaps the days of accountability are long gone.
One of the biggest threats we hear from patients is that they will leave our practice if we don’t write off their balance. Not much that you can do about that. Health care is a business and we cannot pay the bills with altruism. In addition, it is fraud to bill the insurance company for services and write off the patient’s responsibility. Aside from financial hardship cases, routine adjustments of patient responsibility can get a physician excluded and/or fined by the government when it is a government program such as Medicare or Medicaid. Worst case scenario for commercial insurance is the insurance company dropping the physician from their network.
With lower reimbursements, practices really need to devote more energy in collecting all revenues due. The average overhead for a primary care physician practice is reaching 60%. There are no government subsidies for physicians, other than rural health care, community health care centers and native american health centers. More and more physicians are closing their offices, retiring early, selling their practices to hospitals, transitioning to concierge medicine, or going to cash only practices. This is devastating to primary care because of the physician shortage; however, many specialists are also getting hit hard as well.
And then there are the offices (like mine) that see a large CMS population. Many of these financial affairs are managed by their children. Trying to get them to pay the bills becomes a battle. In their mind’s it’s their money! or going to be as soon as Mom and/or pop kicks the bucket. They call and lie! “The doctor said he would take what the insurance paid”. I know this is not true. The docs are not allowed to discuss money or payments with the patients/family, they are referred to me. Having been in the business for over 30 yrs I really don’t know what the answer is for today’s patients in this economy. I do not see it getting any better, at least not in my lifetime.
You said a mouthful. “Entitlement” seems to be the name of the game. It used to be a government thing, but now that government has invaded our Practices so much, it has impacted us directly and replaced the “Doctors are rich” theory. You have described the arguments that ensue perfectly.
fantastic article, I printed it and placed a few copies in my waiting room. Thanks Debbie Alfonso Taylors Mills Family Medical Manalapan, NJ
Thank you, ladies, for you wonderful comments and support!
Your article hits the spot entirely. We are a specialty practice and do in-office diagnostic procedures. Lately we’ve been encountering a relatively new phenomenon called in-network surgical deductibles. Patients are angry about the surprise out-of-pocket expense. They expect us to know how their particular benefit plan will adjudicate the claim. Then they say the doctor was unethical for doing the service (e.g. giving good medical care and thorough evaluation) without first informing them of the additional cost. Doctors just want to trat the patient, not get involved in a discussion about money.
This has been enlightening. I’m a career changer and strongly considering the practice management field as my new endeavor. Clearly, as the nature of medical care is constantly changing, i.e., physicians have to think like business persons and not just as “I just treat the patient, let my PM worry about collecting the fees.” Physician business education as part of their medical training would certainly end the “head in the sand” mentality it appears many have about the busines of medicine. I’ve met many a young physician just starting out who feel frustrated because they are torn between becoming employees of hospitals, physician groups, or an independent physician office.
Likewise a stronger patient awareness of what their respective health plans will cover is equally important. From a personal perspective, my health plan covers a yearly physical. However, I always contact my health plan prior to the appointment date and find out what’s fully covered and what is not. That way I minimize my out-of-pocket costs. If my doctor requires a particular diagnostic procedure not covered, then he/she must tell me why. If they can’t tell me the test isn’t anything other than “I routinely do this” then I won’t do the test.
Better education and cooperation between patient, provider, and insurer form a winning team. Deficiencies on the part of any of the actors causes a less than optimal outcome.
I read your blog while looking for information on how to be reimbursed for our of network costs when your MD does not bill insurance. As a person receiving care and trying to pay my bills I feel like I need to be a super slooth trying to figure out what is covered and what is not. Unfortunately as a patient , parent etc, insurance private payer, we are not always privy to what we are going to be billed for, such as this new phenomenon called “Facility Fee” . It would probably be easier for patients and more acceptable when they do get billed if they got a Estimate of services and potential costs so they know what they might be getting into and can make decisions based on knowledge. Just a thought for change. I like to know my costs up front so I can say yes or no , unless it is a medical emergency.One last thing that could be frustrating your patients is that when you have PPO coverage you have less choice of who you are seeing and how big the bill is. Some providers charge absorbant fees outside the allowed charges of the PPO and then the patient must pay the extra. I have seen doctors and hospitals charge more to those insured than they do cash payers which does not help either. Just some thoughts from the patient side of things.
Totally agree with Stephanie. As a patient, you are at the mercy of the service provider charging whatever they want (especially if you have insurance!) only to discover that the unpaid portion (for which you are responsible) is totally outrageous, because they are looking to recover money however they can. It is ridiculous to have to sign something saying you will pay what amounts to an “unspecified dollar amount”, when you have no idea ahead of time what that figure will be. If the care costs were uniform, we would all be charged the same thing for the same service, and the provider would be more likely to get paid (by more patients) if it was affordable.