Insurance companies affect patients with paperwork for tests

by Jeoffry B. Gordon, MD, MPH

I have always considered it to be my professional responsibility and ethical imperative to fight for my patients with the insurance companies to get approval for every test and medication that I think is medically necessary.

My batting average is close to 100% Lately, the insurance companies have been trying to draw the noose tighter and make the task of getting approval more and more onerous. By establishing these barriers and reviews the insurance companies are obviously adding to their profits (while at the same time promoting and accounting for these programs as quality improvement efforts) and never thinking to pay us extra for the additional work involved.

By my data, the major insurance companies have actually lowered their reimbursement levels for primary care office visits over the past 5 years and, of course, they pay us nothing for the effort of getting the approvals — or for the pleasure of trying to explain a medical problem or diagnosis to a clerk.

Thus, I have drafted up the following notice for my patients:

As you are all aware your health insurance policies have become more restrictive and more expensive and they are becoming more so in an accelerated fashion.  They have imposed increasingly large financial burdens and administrative barriers on you to restrict your access to the medications, evaluations, and treatments that you need to get better or stay well.

As you can imagine these administrative complexities impose a great responsibility on my office. As your doctor, I and my staff are committed to obtaining all necessary and appropriate approvals from your insurance company in an expedited fashion to obtain the care you need. My attitude is that I should be an advocate for you in these matters. My office is especially proud of our track record in confronting the insurance companies to get needed care.

Nonetheless, you should be aware that this responsibility imposes an increasingly great burden of time and effort on us which subtracts from our availability to care for other patients. A recent study in San Francisco showed that the average doctor spends about $70,000 a year dealing with insurance companies. In certain circumstances this insurance process can be especially complex and prolonged and in other circumstances you, as a patient, may want or desire prescriptions or referrals (for example for brand name medications or MRIs) which are especially difficult and time consuming to obtain.

Under these circumstances, at my discretion, I will be imposing a fee of $50 to be paid in advance for the time and effort necessary for me to cope with this bureaucratic morass.

This an important tool for bringing the malfunctioning and anti-patient aspects of this increasingly irrational system to patients’ attention. Just as obvious is the potential for alienating them. I wonder if it is against our provider agreements with the insurance companies to render this charge.

Has anyone come up with another way to cope with it?

Jeoffry B. Gordon is a family physician.

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  • pheski

    I get it. Most patients do not choose there insurance, but are insured by a company selected (with cost a major parameter) by their employer. In order to compete for contracts, the insurers offer lower rates. In order to afford lower rates, the insurers attempt to restrict costs and deny services. (If the government did this, it would be called rationing, but since it is part of free market economics, it is considered a good thing?) And you are proposing that charging the patient a fee will make things better? The insurance companies won’t care. Governments may or may not care. But your patients, even if they were inclined toward sympathy by your plight, will correctly perceive that you are asking them to make up for the failings of the insurance industry.

    If this works, the insurers will tighten the noose more, in the expectation that you will charge the patient for the difference. Additionally, as the amount of care is reduced, it will be proclaimed a further success.

    I’m a family doc and totally supportive of your concerns. You might consider the same letter, but instead of charging the patient, perhaps the name and number of the insurance commissioner, the HR person at their place of work, their senators and representative, and the local paper and talk radio personalities, encouraging the patients to make noise.

  • SarahW

    Would your contract as a preferred provider prohibit the additional fee for what you have already contracted to do at a set price?

    I think the solution would be to strip Insurance companies by law of the ability to interefere in treatment options – they can cap prices or reimbursement, but not determine without some extraordinary burden of proof that a treatment is inappropriate.

  • Vox Rusticus

    How does the OP plan to impose the fee? On all patients, or only on those with carriers that apply preapproval requirements, or those that deny payment after the fact? I suppose this would be called an administrative charge to distinguish it from clinical services, which would likely be more strictly governed by the provider service agreement.

    I don’t disagree with this plan. These extra duties cost real money and they do nothing to further care, serve the patient or the doctor. All they do is reinforce profit for the insurer.

  • Max

    I think your letter and fee is a good start. Think of it this way..the insurance companies had you jumping through hoops like a trained dog. You thought you were being successful by your 100% track record. In actuality, they were 100% successful in getting you to jump through every hoop they put in front of you, delaying payments and treatments. Just like Pavlov’s dog, they whistled and you salivated. Just like most doctors, we cave.

  • solo dr

    Likely the fine print of your insurance contracts will not allow any extra fees. I contacted my contracted plans, insurance and Medicare. Only three plans would allow me to charge a no show fee. Two plans allowed phone call charges. Medicare, which is where I get 50% of the calls, does not allow phone call charges or no show fees.
    Paperwork/prior auths take about 2 hours/day from me and 2-3 hours/day from my staff away from patient care. I have contacted the major insurance companies, as I do not see why I have to prior auth the same med that a patient has been on for five years or a repeat CT to check a pulmonary nodule every 3-6 months until stable, to see if I can charge for this time. The insurance companies claim it is included in the office visit time, and there is no way to do multiple scheduled CT prior auths for the whole year all at once.
    What I end up doing with most patients is if they have not had a recent office visit for a med that needs prior auth, I block up to 25 min and do the prior auth with a cell phone at the visit. I bill by time, with greater than 50% of the time spent counseling the patient about meds, which would be level a 4. Since the insurance companies have told me in writing that they will not pay for the faxed forms or prior auth forms or my time on hold with the MO pharamcies, as the E&M should cover it, I am abiding by their rules and getting paid for my work

    For MRIs/CTs, as sometimes I don’t know ahead of time if it will be needed, I schedule it at the appointment with the patient in the room. This also usually is a level 4. I then make the patient follow up for the MRI/CT, as a $2,000 test should be worth the $20 copay to go over results. I try to do the prior auths on speaker phone with the patient, but one of the major prior auth national imaginag companies refuses to allow me to have the phone on speaker in a sound proof room with the paitent, as they are afraid of what the patient might hear from the medical director or the form questions that are asked prior to obtaining an RQI number or CC number.
    FMLA and disability papers are a gray area. There is a CPT code for paperwork, but most plans will not cover it, or they assign the billed charge to the patient. Most of my area practices charge extra for it, but some contracts consider that billing extra. FMLA papers, in my office for complicated conditions, also require two office visits. If the initial time is for back pain, then the patient needs a follow up visit 1-2 weeks later to make sure the back pain has resolved.
    These tips to do not always work, and I figure I give away around 10 hours a week toward free paperwork time to the patient.

    • WarmSocks

      I then make the patient follow up for the MRI/CT, as a $2,000 test should be worth the $20 copay to go over results.
      I was with you until here. As a patient, I have no problem with my doctor making phone calls on my behalf right there in the exam room with me. It sounds like a great idea.

      But making patients return for test results? No. First, it sounds arrogant to say you’ll make patients do something. Second, when I have tests done, I ask the person performing the test if there’s a release/form I need to sign so that they can mail me a copy of the results. Visting my doctor for the results is not necessary. Most importantly, it’s not just $20. It’s making time in the schedule for another appointment. People can lose their jobs for taking too much time off work. Maybe you only see it as taking fifteen minutes, but patients have travel time to consider. We need to arrange for someone else to cover our responsibilities while we’re away. When I go in for an appointment with my doctor, it affects five other people’s schedule for at least three hours. The $20 co-pay is nothing compared to the hassle of actually travelling to the doctor’s office.

      • stargirl65

        I don’t mind if you want to get your own copies of the results and interpret them as you wish. But don’t call me up the next day and want to have a long conversation with me about those results. I am seeing the patients with appointments. If you want to discuss the results with me then you should make an appointment for my time. Another option would be you willing to pay for my time with a phone consult. I also will get patients that will call and want me to interpret a test SOMEONE else ordered and make recommendations. I may not have seen this person for a year or more. Should they come in to discuss the results?

        • WarmSocks

          Yes, patients should pay you for your time and expertise if they want you to explain their results (regardless of who orders the tests).

          I am happy to make an appointment to discuss abnormal results and learn about the resultant diagnosis and what to expect from treatment. I would happily schedule a phone appointment and pay for a tele-consult to avoid the drive to see my doctor. Alas, that isn’t something that can be done. Yet.

          I have, in the past, made an appointment with my FP just to ask questions. Not everyone expects their doctors to work for free.

          • stargirl65

            I like your approach. I agree that the discussion of normal results does not require an appointment and I generally do not request one. I just send the results along.

  • Michael F. Mirochna, MD

    Doing admin work in front of the patients is genius. More time with the patient and they get to see what we are doing.

    When you bring patients back for results… what exam do you do for that? The HPI is just a summary of the reason you ordered the test? ROS?

  • Jeoffry B. Gordon, MD

    Just as a footnote:
    Nothing in the recently passed health care reform legislation gets to the level of detail that it might eliminate or rationalize these onerous procedures – or develop proper reembursement for the professional time spent.
    Also you can bet that the insurance companies will be fighting to allow the costs of these PA activities as a bone fide quality assurance activity and thus an allowable medical expense under the new medical loss ratio limitations.

  • KP Internist

    Don’t like to submit a bill. You don’t have to if you are salaried.

  • Killroy71

    The more patients understand about their care and their coverage, the better. Maybe patients can even do some of this legwork you want to charge for, if they know what’s required. Doctors always say they don’t like insurance companies telling them how to practice medicine, but they aren’t the ones who get complaints about rising premiums. To that point, I take issue with your statement: “By establishing these barriers and reviews the insurance companies are obviously adding to their profits …” — actually, no. Profits longterm are in the 2-4% range — if they look good this year, it’s only in contrast to the past two years. Insurers also have a responsibility to your patients by keeping coverage from being more unaffordable than it already is — hence asking patients and doctors to take a close look at usage. Doctors would like to think their practice is above the “cost” fray, but they like getting paid. And if — by your calculation — payment has gone down, maybe that only means it hasn’t kept up with medical inflation — neither have wages, in case you hadn’t noticed.

    • Jeoffry B. Gordon, MD

      You have been snookered by the insurance companies. Their 4% profit claim is based on their accounting for premiums paid as earned income. If you base their profits on their actual business activities performed they earn closer to 20% profit. For comparison please note that banks do not account for “deposits” as earned income.Also what ever the percentage is, the five biggest national health insurance companies had $12.4 billion in net income in 2009 (up 56% from 2008) while serving 2 million fewer enrollees that year.

  • stargirl65

    solo dr:

    Medicare does allow no show fees as long as they are the same fees applied to all other patients that do not show. I received a notice from Medicare a few years ago to this effect. Also the patient must be notified ahead of time. A simple sign in the waiting room will suffice.

    Medicaid does NOT allow the fees. I no longer participate with Medicaid because their no show rate was high, reimbursements low, complication factor high, and you cannot charge for things like forms and no shows.

  • C. W. Spencer

    Dr. Gordon:

    You may not be aware of a recent ruling by the OIG. The reference for this ruling is OIG Advisory Opinion No. 10-04. In essence this ruling allows the imaging center or hospital to obtain the precert for you. The center or hospital is required to offer this service to all providers to avoid any “kick back” violations. I would see if any of the facilities you use for services are offering this assistance. I believe you will see more centers and hospitals offering this service over time. The delay will be devising a team to do the precerts. Once the provider community understands this service is available the center or hospital will need to be prepared for the volume they will receive. This is a win, win solution for all. It will save you and your staff precious time and expense, the patient avoids the “fee” and the center or hospital will receive compensation because the precert will be correct for the required procedure. Hope that helps a bit.

    • Jeoffry B. Gordon, MD

      This is helpful and practical observation. However, it overlooks the underlying problem: that the insurance companies are imposing a time and effort burden on providers of medical care without any compensating payment. Whether it is my doctor’s office or the hospital or radiologist’s office the burden of bureaucracy and expense are diverting provider resources from patient care to the insurance company’s benefit.

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