by Marie Cooper

Consider two patients with the same managed care plan.

One has multiple sclerosis and receives an infusion of Tysabri every month. It needs pre-certification. The requirements are black and white. The patient qualifies if they have relapsing/remitting MS and have failed other therapies. The drug costs $2,000, the infusion center is another $1,000. The infusion center is a contracted provider that has two of their staff people dedicated to keeping track of needs for referrals and pre-authorization’s for their patients.

To the patient, this is a seamless process. She shows up every month and receives her treatment. She has no co-pay. Patient A loves her insurance plan.

The second patient had a fall and broke her right humeral head a year ago. Following an open reduction internal fixation, she has physical therapy three times a week. PT has been effective, but recovery is slow. Things are fine until the tenth week, when PT is denied, as the patient has a PT benefit of 30 visits per injury per year. The patient and the physician are incensed. This is medically necessary. The doctor has ordered it. The patient needs it. But the contract says only 30 visits will be covered. Two levels of grievances uphold the decision, it is a contractual exclusion. The patient is welcome to continue attending physical therapy. But the insurance company will not pay for it. Patient B hates her insurance plan.

Patient A and Patient B are the same person.

I use these examples to show the best of managed care and what makes people unhappiest about managed care. Managed care is designed to save money and increase profits while paying for needed care. Americans, in a culture that traditionally wants to have its cake and eat it too, has a love/hate relationship with their insurance carriers because they don’t necessarily get everything they want when they want it.

Insurance is a business and, for now, it is here. It what we have. The old days are gone and are not coming back. So I suggest the best way to cope is to deal with it.

I don’t mean that to be obnoxious. I mean deal with it in a way that is productive and emotionally healthy for doctors and patients until something better comes along.

Doctors
* Have one person (or more) in your office dedicated to dealing with managed care. Or, for practitioners with small offices, hire a part time consultant. It will pay for itself in better organized claims and increased revenue.
* Know the rules; understand that these are contracts and if something is contractually excluded, that is it, it is just not covered. It is not a malicious plot, it is a business model intended to save money, employer money and employee money. Almost all of the time, it is the employer who chooses limits in a plan, not the insurance company. And the limits are chosen to save money.
* Document everything the patient says about their condition, even if it seems innocuous or offhand. That way down the road, if something needed 6 months of conservative treatment, you have it documented. Too many progress notes simply say “no complaints” or “better”, which practically begs a denial.
* Know the criteria for your most common procedures so you can have the documentation to back up your request.

Patients
* Read your Evidence of Coverage – the book you get when you enroll. Know your benefits and their limits.
* If you don’t understand something in the EOC, go talk to your benefits rep in the Human Resources deptartment.

Remember that insurance is a business. It is not personal. If something is denied, look at your part in the process. Did you follow the guidelines? Is it a contractual exclusion?

It is not a perfect system. There is greed, carelessness and errors. It can seem complicated and capricious and unfair. But it can work.

However, if providers and insurance companies don’t work together, everyone suffers. Doctors do not receive their well-earned compensation. The insurance companies cannot sustain themselves financially because they will lose members. But most of all, it is the patient who loses the most if providers and insurers continue their hate fest.

Marie Cooper is a freelance writer and management consultant at Achievement Strategies.

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