Tricks of the Trade- Medical Review of Claims
The Health Insurance Company will deny your claim by using a "Gimmick", a contrived procedure called, "Medical Review of Claims and Benefits" which is intended to result in denial of claim. This process of "Denial of Medical Claim" is a pretense and masquerade. Under this "review of care" procedure, the insurance company proposes the medical claim fails their "Guidelines", and is therefore denied. How are these "Guidelines" created?
Denial Based on Guidelines
Guidelines are created by health professionals employed by the health insurance company who work for the benefit of their employer. Their job is to create guidelines that deny health care. These "Guidelines" have no application to the way your doctor actually practices medicine. If your doctor follows the "Guidelines" then he has unwittingly become an agent of the insurance company, allowing them to dictate how he practices medicine. What to do if your claim is denied? Appeal
Manufactured Excuse for Denial of Claim
The guidelines provide a manufactured excuse for denial of care based on one of the following:
The guidelines have determined that the health care is medically unnecessary, experimental, dangerous to the patient's well-being, or outside the standards of care provided by a professional association or governmental agency.
The healthcare may be denied because it uses an off-label indication (for a medicine or device).
However, the real reason for denial of the claim is obvious; the claim is denied because the health insurance company payment of your claim will result in lost profits. The health insurance company prefers to keep your entire monthly premium payment as profit, rather than pay a claim.
Prior Authorization-Another Trick of the trade
The Insurance Company had decided that certain tests and treatments require "prior authorization". Seeking prior approval consumes inordinate amounts of the doctor's time, which is not compensated. Because of this uncompensated time, the doctor may avoid seeking "prior authorizations", thereby avoiding the best treatment or best medication, device or procedure. In fact, the doctor would rather walk on a bed of hot coals rather than hang on the phone with clerks seeking "prior authorization". To secure approvals, the doctor may be forced to exaggerate the urgency of the medical condition or use creative medical coding.
Fee Pressures from the Insurance Company
The health insurance company does not pay ordinary and customary doctor's fees. Instead, the health insurance company creates their own fee schedule, paying a fraction of the usual fees. The physician has the choice of either accepting this paltry fee schedule, or opt out of the insurance system. If the doctors accept the insurance fee schedule, they are faced with financial ruin, as the resulting income is insufficient to support a medical office.
Cut the Fees, and Increase the Volume
If the physician accepts the insurance company skimpy fee schedule, the physician is faced with shrinking income. The only remedy is to cut patient services by increasing volume to 60 patients a day, and by so doing, profoundly change the quality and level of the practice of medicine. Seeing sixty patients per day allows only 5-10 minutes per patient, making impossible a true health care encounter. Can a physician deliver ethically responsible health care in 5-10 minutes ? I don't think so. You try it and let me know.
The result has been a lower quality of medical care, increasing malpractice litigation, a loss of confidence in the medical profession, a loss of physician self-esteem, and an unbearable economic burden on our nation.