Insurance Confusion. Please read and submit your comments!

I love my job. There are so many things to love, including helping kids get well and watching families grow together. Pediatricians get few instant gratifications, but many overall satisfactions of knowing we make a difference in the lives of children. (Warm heart!)

I knew there would be stresses to my job. All jobs have stress, and I expect things like

• time away from family working on weekends and holidays.
• sleep loss when there are urgencies or emergencies when I'm on call.
• sleep loss when there is a call about a non-urgency. (I do dislike those quite a bit, and yes, they do happen. Please respect our sleep and call during business hours for routine questions.)
• having to give bad news to a family of a very ill child.
• hearing stories of bad social situations and not being able to help immediately.

But one of the biggest stressors for me has nothing to do with the above. It has to do with billing and insurance. I keep thinking that if we educate our parents it will get better, but it doesn't. People who don't know their policy are upset about the charges left to them after the insurance company adjusts the bill and pays their portion.

Source: Shutterstock

During the summer we do a lot more physicals than other times of the year, so the end of the summer through the fall is when the phone call volume really picks up.

• If I knew there would be a charge for the autism screen I wouldn't have done it. Two autistic children recently diagnosed had a delayed diagnosis because parents refused the screen due to cost. Both families said they had no worries so didn't want the screening... so not screening isn't the answer.
• If I knew there would be a charge for the depression screen I wouldn't have let my teen take it. One of these complaints was a parent of a teen with a positive screen. The child was depressed and the parent hadn't suspected it. It is sad that even a positive screening is not worth the cost to a family due to financial circumstances, but every dollar is important for people paying bills. Yes, our health insurance system is broken!
• You should have told me there would be a charge for the ear infection treatment. They usually still want treatment for any sick symptoms. And I did warn them by email and the note posted in the exam room, but they usually say they were too busy to read it.
• I didn't know the lung function test wouldn't be covered by insurance. Neither did I. I don't have your insurance contract.
• I didn't know there would be a charge for ear wax removal. I couldn't see your toddler's eardrum. With that runny nose and poor sleep, it was important to remove the wax to see the eardrum.
• The list goes on...

I think the business of medicine stresses me more than the medicine because it is not what I'm trained to do. We have a business office that handles our billing and collections. I really don't want to get involved in that too much. It is a slippery slope. A big concern of mine is that I don't want to get involved in the billing because I don't want it to alter the way I practice in a negative way. Yes, I need to know the issues so our office can develop procedures to limit costs to families. I do believe that is important. But I don't want to follow medical practice guidelines on a subset of patients who can afford it and not do the recommended care for those who can't. If I do these services only for people who can pay for them (or those who know insurance covers the cost), I am not practicing good medicine for everyone. 

Guidelines are made by committees of well educated people who review all of the data and come up with the best ways to manage various issues. They recommend when we should do things, such as depression screenings, lead screenings, asthma follow up, get an X-ray, use a prescription medicine, and more. If I don't follow those guidelines simply because of cost, I am not providing great care. I only want to provide the best care. 

And if you bring up a concern at a well visit and I remind you that to discuss it might incur a charge to you, am I medically liable for not addressing it when you decide you no longer want to talk about it? It certainly won't get documented in the medical record, which means when you ask about it at a future visit I won't remember you mentioning it before. This can compromise good care because there isn't a good record of symptoms that could have been available if it was properly addressed at the visit. 

Our office really does try to help people with medical insurance issues.

On one hand, we try to limit costs to people. 

• If one drug is usually expensive, we try to order a cheaper option. (But we never know your formulary, they are all different and change often!)
• If I know a referral to a specialist probably won't result in any treatment that I can't offer, I will recommend against it. (If I think the specialist can offer more than me, then I am happy to refer so your child will get the best care. But don't call me when they charged more than you thought they should. Call them.)
• Our office offers extended hours so people don't have to go to the emergency department or urgent care (usually insurance charges you more for those services). 
• I try to talk parents out of vision screening in my office because if their insurance only pays for one per year I want it done by an eye specialist, not me! (See the 2nd scenario for more on this one.)

On the other hand, we try to anticipate and tell people in advance that insurance plans vary, and it is their responsibility to know their plan.

• We have a page dedicated to insurance on our website.
• Each of our well visit pages on our website reminds parents to check insurance.
• Before every well visit all patients registered on our web portal get an email with many important things regarding the upcoming well visit, including insurance issues.
• We have signs posted in each exam room reminding parents that separate issues discussed might incur a separate charge based on insurance.
• I post about insurance issues frequently on our Facebook page.
• I blog about this issue at times. Here. And here. And here. And here. And here. And of course this blog.

Yet the phone calls continue. Parents are upset about the way we charge them for things. This is misleading. Yes, the bill comes from us, but it we are only billing them what their insurance company tells us to.

Health care billing is complicated. We provide a service and apply the standard codes for each thing we do. Each code has a charge attached, based on typical payment for that code. We submit those codes to the insurance company. The insurance company adjusts the payment amounts to what our contract with them states they think are reasonable charges. Some companies allow more payment for one code, less for another. But it's not our choice how much they think is reasonable. We must write off the amount over their reasonable charge cost. The insurance company contracts with its clients to determine how much of each of those reasonable charge costs will be paid by them, and how much is the client's responsibility. We never see those contracts, so we don't know how much you will be billed at the time of service. We send the bill to the family based on what their insurance company tells us. We cannot adjust that amount -- to do so is insurance fraud. Simple as that. I'm not willing to commit fraud to decrease your bill, no matter how much I like you and understand your financial hardship.

Everyone in my office wants to provide good care, so we discuss guidelines and insurance issues in addition to other office policies and procedures on a routine basis. We review our practice for quality. We often hear complaints from staff that they want us to stop doing a recommended screening because they are tired of hearing complaints. But we continue to offer those that continue to be recommended because we care about the health of your child. We want to do what's right, not what's cheap. And I suspect that insurance will become more costly to people as the new plans roll out. Either you will pay a large premium to have more services covered, or you will pay less monthly but be expected to carry more of the load when you use services. 

Request: Please share how you think we can do it better. What are we missing? How can we better educate all of our families without spending the entire visit talking about possible charges instead of your child's health? We can't change the system (though that's the ultimate fix) but I want to know how we can make the system work better for all.