A Day in the Life ScenariosHealthcare PolicyPhysician Office Issues


On June 15th, the Washington Post carried an article reporting on American health care  consumers’ satisfaction with their health insurance. The pertinent statistic quoted was that nearly 6 in 10 Americans “experienced at least one problem with their health insurance in the past year.” A few of the “problems” were denial of payment, difficulty finding a doctor in your network, or learning a service is not covered when you thought it was.

While 6 in 10 patients (60%) have problems with their health insurance, 10 out of 10, or 100%, of physicians have problems with their patients’ insurers. Every single health insurance payer, whether it be Medicare, Medicaid, Tri-Care, Aetna, Cigna, Anthem Blue Cross Blue Shield, or Poor-Paying Mutual, causes problems for physicians and their billing clerks. The lay public has no idea how difficult it can be to get paid by insurance payers. This is not a new problem. It’s been like this for decades. It’s as if health insurance companies mistrust physicians so much they are trying their darnedest to keep from paying a claim. 

Health care insurers are notoriously slow payers. It can take several weeks to months for payers to decide if your claim is worthy of payment. An extreme example occured in the 1980’s. I delivered the baby of a mother insured by CHAMPUS, now called TriCare. CHAMPUS was the health insurance plan for active military people and their dependents who didn’t have access to a military medical facility. The patient was the dependent wife of a sergeant. For unknown reasons it took CHAMPUS 3 years to pay that claim. I had given up pursuing it, but one day, out of the blue, we received a check. Unbelievable!

The biggest problem physicians have with insurers is denial of payment. There are several reasons why, and all of them due to unreasonable requirements imposed by the companies. One small error on the claim form, an incorrect diagnosis code or procedure code, or codes that don’t match correctly, can land a claim in non-payment purgatory, never to be heard from again. Incorrect claims must be corrected and re-filed and evaluated for payment a second time. We might get lucky and be paid the second time, but we also might not! 

Filing a medical claim is not a simple task, either. It involves choosing the correct diagnosis code and matching it with the appropriate procedure code. If these codes are incorrect, denial of payment is a certainty. Then the physician must correct his mistakes, re-file the claim, and wait again for an answer. Every claim that needs refiling delays payment and affects your financial bottom line.

The normal way to resolve such problems is by calling the insurance company and getting help from a representative, if you can get ahold of one. On one occasion, my receptionist was on hold for an hour waiting to get help. The representative who answered was having a bad day and was rude  and not helpful. Also, different representatives will give conflicting information so you’re never certain you’re submitting a “clean” claim, the term used for a correctly submitted claim form. 

While 60% of patients have one health insurance problem each year, physicians have these problems multiple times every day! It’s maddening, frustrating, and wastes time of the doctor’s staff. The government’s ultimate solution to the problem is to have a single payer (the US government), put doctors on a salary, and eliminate fee-for-service payment. That erases claims, claim forms, and complicated codes. A national health care system would change everything about medical care. It would appease patients but alienate 95%of physicians. Let’s hope the current system can maintain itself, but changes are necessary because it’s far too complicated and must be corrected without blowing it up and starting over.

As I’ve written in previous blogs, customer service is lacking in every aspect of medical care. Patients are never put first. Long waits for anything are an accepted norm, and patients are often met by rudeness, arrogance, and indifference by staff. All this must change, but a nationalized system is not the answer. My answer is for health care providers to remember they are servants of their patients and show more selflessness. Do things for patients that show them you care. Stay after five PM until patients quit calling. Communicate better, listen better, sacrifice your time for their benefit, and show them you care. Don’t send non-emergency patients to the ER. See them yourself. If the patient needs an MRI sooner than 2-3 weeks, call and schedule it yourself. An open appointment will suddenly appear. Doing things for patients within reason is good for the doctor-patient relationship, and restores a patient’s faith in the doctor and the system. 

It’s an oversimplification to say health care will be better just by being nicer to patients, but it’s a start. Medicare and private insurers are set procedurally and have no intention of changing. So patients and doctors will always experience problems. It’s a given. If there weren’t so much Medicare fraud, physicians would be trusted to submit honest claims. Unfortunately, in some specialty areas fraud is a huge problem. Like a lot of things in today’s world, if truthfulness and honesty were practiced regularly, people would get along and the world would be a better place. It’s worth a try.

Reference: AAFP Family Medicine Today, “Nearly 6 in 10 Americans Report Problems with Health Insurance Coverage During Past Year” 2023 June 16.

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