By Rebecca Levy-Gantt, D.O.
Napa Valley (Calif.) Register, July 28, 2020
You would think as a physician and owner of a small private solo medical practice I would be against a Medicare For All, Single-Payer plan since that approach would have doctors earning a salary and not allow earning more for doing additional procedures and visits.
Well, I say, bring it on.
The private insurance system is unsustainable. Without major change, I will not be in private practice much longer.
The last six years of running a private practice has been my education in private health insurance. If I contract with a particular insurance plan, we take that insurance. If a patient has a Preferred Provider Organization (PPO) plan like United Healthcare or Cigna, we can likely see them since I have contracted with those plans.
A significant drawback of health maintenance organizations (HMOs) and PPOs is both limit patient freedom to choose. I am contracted with many insurance companies, but a contract does not guarantee a particular company will pay for my services.
Each company is different. One will pay for preventive care, but another will not. The guidelines are rarely clear. If I am planning a biopsy in my office, and if we have called the patient’s insurance company for authorization, getting that authorization does not guarantee the insurance company will pay the cost of the biopsy.
This is our process: we call for authorization, get approval for a procedure, and bill the insurance company, but half the time the insurance company then decides not to pay or the patient must pay a larger portion. We often have to appeal or resubmit bills or remain on hold for hours to discuss the authorization with an insurance representative.
In what world would this be acceptable? Can you imagine telling your plumber after your pipes were fixed that you would pay nothing or only 40 percent of the cost? Then you make your plumber wait three months for payment?
We physicians have no automatic explanation of benefits that pops up when patients give us their insurance card. Contracts are confusing, vague, and contradictory. This is so even for my staff of insurance experts.
We do not know if something will be covered sometimes until after the service has been authorized and provided. We bill the insurance company, only to receive a notice: “This is not a covered service.”
This occurs even when the exact service was covered last year with the same insurance company.
I recently delivered a baby. In the sixth month of pregnancy, my office called the patient’s insurance company to ask about coverage for the delivery. She was informed that “the patient’s delivery will be covered at 80 percent of the contracted delivery rate.” We then know the patient will be responsible for 20 percent.
After the delivery, the bill went to the insurance company. We expected to receive 80 percent of the contracted fee from the company. We did not. The insurance notice said “This is not a covered service. No payment is forthcoming. The patient is responsible.”
My biller spent over two hours on the phone trying to understand what had happened. A second insurance representative recommended “resubmitting the bill.” We did so.
We are still waiting.
In what world would this be an acceptable practice? Two months have now passed. Once three months go by the insurance company can refuse to pay because of a “delay in billing.”
More time on the phone. More money uncollected.
If I want to care for their patients, I must sign the contract the insurance company presents. If I do not, I cannot care for patients with their insurance.
I cannot negotiate. I have tried. The contract is “take it or leave it.”
This is anti-small business. Our country was founded on the idea that individuals and small businesses were the backbone of our nation.
The only reliable coverage is Medicare. If a rep says ‘yes,’ they mean ‘yes.’ An approach where the government pays the bills seems to be the answer. We would be removing barriers standing between patients and health care providers.
When people say some love their insurance, it is not their insurance they love but their providers. Single-payer health care has a proven track record.
We look to Canada, Taiwan, and South Korea where the population lives longer and has a lower maternal death rate.
If the health insurance industry remains as is, I fear that small private practices such as mine will no longer be an option. The dream I worked so hard and so long for will die, and I will have to start the slow process of closing down my practice before the insurance companies help to close it down on me.
