Aiding and Abetting: How Primary Care Physicians Who Bill Insurers Help the Insurance Cartel
I thought I would give you all a bonus blog post today. The following is from Jeff Gold, MD, a good friend of mine. It is worth sharing:
Warning: Insurance Accepting PCPs could be triggered here. Hint: That’s kind of the point
A few weeks ago ProPublica published an article titled “How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them” about how physicians working for Cigna- the “C” of the BUCHA Cartel- help increase CIGNA’s profits by rejecting an insane amount of claims per minute. So, the article made the usual rounds on LinkedIn, medical blogs, etc pummeling the evil insurers and the doctors that work for them. This did not surprise me one iota, but what does continue to surprise me is the lack of mention of the doctors that submit these claims by the millions. Do people ever wonder why claims sent in for a doctor to spend 8-10 minutes with you to check some boxes on a screen, do a quick ear check, look in your throat, listen to your heart and lungs, refill a medication you have been on for 5 years, and now ones submitted for 5 minute video/email visits are all accepted and paid out with zero resistance? Yet, the lifesaving drug or procedure is often rejected- or at a minimum require 15 hoops to jump through to get paid? Imagine Valvoline sending in claims to GEICO for my windshield wipers to be replaced, my oil to be replaced, my tires to be rotated and getting paid easily, but GEICO not paying when a tree falls through the roof of my car? It makes no sense. Yet this is the ass backwards world of health “insurance” we are talking about here- the one where you get your “free” 250-dollar mammogram annually but then get exposed to 3,000 minimum for most if the mammogram is abnormal and further testing is needed. Now keep following me closely because this is where it gets confusing.
When I (well my employer actually) filed claims to insurers for day to day medical issues I had no awareness that I was actually helping the insurers generate more profit due to my ignorance. How many times do we hear- or have said- “let the insurance company deal with the claim and pay for that 75 dollar lab because I pay a lot for my insurance. Its the least they can do. Just bill the bastards”? By believing this we rob ourselves in 2 ways. Number 1 is the simplest to understand. There is no free ride. When the insurers pay for something it is usually at an insane markup and is always added on to next years premium, deductible, copays, coinsurance etc. Again I repeat…nothing is free! Number 2 is a little more confusing as it is due to the MLR or Medical Loss Ratio. The ACA has a rule that insurers need to pay out 80% of premium dollars in claims for small groups and 85% for large groups. The remaining percent goes to their operating costs and profit. Remember, these are companies whose main responsibility is to their shareholders not you. Go check their stock prices I implore you to. I would insert an article or graphic to support this but I am too lazy. Maybe Doug Farrago has one? Now the rule is that if they do not meet this requirement they have to issue rebates to their customers, but again, even if these occurs what do they do? Just raise premiums. THERE IS NO FREE RIDE!!!!
Ok back to Number 2. Sorry for the tangent. The key with the MLR is that it is a PERCENTAGE. How does an insurer generate more profit in the world of health “insurance”??? THEY PROCESS MORE AND MORE CLAIMS!!!! Bigger pie-> Same percentage-> BIGGER PROFIT!! So the next time you show up to work to see your 18-25 patients a day at 10-15 minutes a pop and file those 99213s, 99214s, 99215s, lab codes, meds at the pharmacy, etc etc realize now that you can not go home and bitch and moan about what crooks these companies are. YOU my friends and colleagues are buying the getaway car, filling it with gas, and speeding off at 95 miles an hour all the while you are harming the same people you took an oath to protect. Do no harm is do no financial harm. And here is the worst rub of them all- if you did get stopped by the police and sent to the clink you will be tried and judged alone. It will be you that is blamed and indicted. You will be thrown under the bus and backed over so quickly that being in the hoosegow may actually be safer than the day-to-day scam on the American Public that you are currently aiding and abetting. Now off to go get my Kevlar on.
Dr. Gold can be found here: Gold Direct Care
Just read the article on Cigna. It made my stomach turn. The corruption, the dishonesty in EVERY aspect of our lives is truly depressing. Don’t know how society can survive this. It is overwhelming.
Well, I think there is a place for everyone, and this moron has a place. If he wants to accuse me of stealing from my patients by taking care of them, I suspect he might actually make some kind of income and he probably gets that money from somewhere and it’s probably from his patients. Now, if he thinks that accepting insurance is the issue, then he is probably doing direct primary care.
Which is insurance.
He has a very narrow network, a network of one, but it is still insurance. He takes care of some people who are much more complicated than others, and overall the difference in acuity and severity of the patients balances out so that he can get his work done in a day. I am no different. I have some patients that are quite simple and I charge a 99213 just like the other ones who are not as simple also at the same rate. It balances out and that is how his insurance works. Everyone pays him and everyone gets back as they need. It is, of course, extremely socialist. But that is where I am at as I accept insurance and that is where he is at as he accepts insurance too – but from a much smaller company, his own. From each as they can, to each as they need. That phrase is borrowed from Atlas shrugged, and if he would like to shrug, I am sure he can work somewhere for free if he is otherwise wealthy. I am not. I will continue to drive the getaway car.
The difference is he does not work for the middleman. You do. You can get pissed about it. Fine. But DPC is not insurance. It is a membership model. DPC docs work for the patients; if they don’t like it, they leave. You work for different insurers trying to please them. Coding. Metrics. ROS. All garbage. I’m with Dr. Gold. So, maybe I am a moron too?
I feel like there could be a “moron revolution” here kind of like the last scene in Revenge of the Nerds… “ you know Jeff I’m a moron too and I’m pretty proud of it.”
But hey at least we know the definition of insurance
That I call dpc insurance isn’t a new thing. It’s the single biggest concern of the movement because doj etc are wondering if they want to apply thousands of pages of regulations that apply to healthcare insurance to dpc. Don’t shoot the messenger on this. Everyone having personal responsibility and do as they think best is a good rule – doctors aren’t, as a rule, bad people. Accusing everyone that takes insurance of theft is at least a bit moronic. Feel free to call me wrong, misguided, stupid. Absolutely I have given over to the dark side and I work for the middleman. Don’t say I’m immoral for giving up my entire life for this profession.
ON a personal note, I want all PCPs to leave the system. And all specialists. But that’s to discuss at another time
The problem is over 50% of the people in the US do not pay much at all for health care. Medicaid, lower income Medicare, and public workers, and some tech companies the patients get everything free. Thus there goal is everything should be covered, and is free for them.
The rest pay exorbitant sums.
The solution is that insurance should only pay for catastrophic, but the forces that would deem that not fair, or then I wont get preventative care scream.
It is staggering how callously one can disregard the ability of less well-off persons AND simultaneously disregard both the economic and public health evidence that an insured population is a more productive and happier one. Even payers have recognized that their bottom line is aided by ensuring that healthcare is *most* accessible to those who are *least* able to afford it.
The American culture is predicated on “let’s dick someone and put in zero effort!” The results are coming in, not so good. If ECONOMIC DEPRESSION hits soon, fine by me.