Reform Health Care Now: Insurance reimbursements make no sense
Published: 2009-06-24 14:50:41
Author: Russell Turk, M.D. | Daily Finance | June 2, 2009
When I opened my own medical practice more than four years ago, I decided to do my own billing so I could learn how medical billing worked. Instead of hiring an office manager, I handled all disputes with the dozen or so health insurance companies whose plans I accepted as well as Medicare and the state-run Medicaid program.
It was a rude awakening. I was not new to medicine -- I had spent five years in another private practice and another six years working for Kaiser Permanente -- yet I was shocked to learn that getting reimbursed by a health insurance company is often a game of coding and standing up for what's right. And if I wanted to get reimbursed for my work, I needed to learn how the system works -- or I might not stay in business for long.I soon realized that that insurance company reimbursements are often arbitrary and nonsensical. For example, the majority of insurers won't pay you for both a routine checkup and treatment for another problem at the same time. If a patient comes in for her annual Pap test and she suspects she has a cyst, the insurance company expects the doctor to either evaluate the problem and not get paid or ask the patient to come back for a separate visit if the doctor expects to get reimbursed for providing both services. Obviously, insurers are hoping that physicians take care of all of a patient's problems in one visit so they don't have to pay for all of doctors' work.
The same is true if a doctor has to perform two surgical procedures on a patient. If a doctor is doing a hysteroscopy to remove a polyp but the same patient also wants an ablation to reduce heavy menstrual bleeding, many of the insurance companies bundle the two codes together and only pay the doctor for one procedure. Even if two procedures are done in different areas of the patient's body, some insurers reduce the payment of the second procedure by as much as 50 percent. Insurers know that physicians would never be so unethical as to make a patient undergo two separate surgeries, but it appears that they have no problem not paying fairly for extra work performed.
Full story
Published: 2009-06-24 14:50:41
Author: Russell Turk, M.D. | Daily Finance | June 2, 2009
When I opened my own medical practice more than four years ago, I decided to do my own billing so I could learn how medical billing worked. Instead of hiring an office manager, I handled all disputes with the dozen or so health insurance companies whose plans I accepted as well as Medicare and the state-run Medicaid program.
It was a rude awakening. I was not new to medicine -- I had spent five years in another private practice and another six years working for Kaiser Permanente -- yet I was shocked to learn that getting reimbursed by a health insurance company is often a game of coding and standing up for what's right. And if I wanted to get reimbursed for my work, I needed to learn how the system works -- or I might not stay in business for long.I soon realized that that insurance company reimbursements are often arbitrary and nonsensical. For example, the majority of insurers won't pay you for both a routine checkup and treatment for another problem at the same time. If a patient comes in for her annual Pap test and she suspects she has a cyst, the insurance company expects the doctor to either evaluate the problem and not get paid or ask the patient to come back for a separate visit if the doctor expects to get reimbursed for providing both services. Obviously, insurers are hoping that physicians take care of all of a patient's problems in one visit so they don't have to pay for all of doctors' work.
The same is true if a doctor has to perform two surgical procedures on a patient. If a doctor is doing a hysteroscopy to remove a polyp but the same patient also wants an ablation to reduce heavy menstrual bleeding, many of the insurance companies bundle the two codes together and only pay the doctor for one procedure. Even if two procedures are done in different areas of the patient's body, some insurers reduce the payment of the second procedure by as much as 50 percent. Insurers know that physicians would never be so unethical as to make a patient undergo two separate surgeries, but it appears that they have no problem not paying fairly for extra work performed.
Full story