Why are some doctors giving their patients prior authorization training and teaching them about medical billing and coding services?
On June 19, 2023, my blog was “Why Do Doctors Hate Their Jobs?”
There’s more to this story that needs telling. Which is the burden and punishing conditions that health insurers create not only for doctors, but also for hospitals, you and I. Your health insurance company has made basic health coverage so difficult, some doctors are training their own patients to help untangle the mess.
For example, the prior authorization process is an artificial roadblock created to slow down or stop you from getting necessary medical treatment. Insurance companies require a prior auth for many medications and medical procedures that would hurt their bottom line.
To obtain prior authorization, the doctor must sit on hold, and press endless phone menu buttons, all for the “pleasure” of getting an interview with a phone agent from your insurance company. They ask for detailed private health information about you, the patient, and the medication or procedure your doctor has ordered. After the interview is completed, the agent faxes your doctor an extensive blank form to be filled out.
Now, your doctor must painstakingly fill out the form, fax it back, and wait. Your prior auth could be denied, or they could request more information. You may be required to get additional testing, visits to specialists, or a variety of other requirements before they are willing to pay.
In some cases, they want your doctor to do a “peer-to-peer” call, where a doctor who works for the insurance company meets with your doctor on the phone. The insurance company hopes that your doctor will be intimidated or has not the time to go on this merry-go-round once again because she is taking care of patients. The system is carefully rigged to prevent you from getting the care that was originally promised by your health plan.
Prior authorizations are a significant source of stress, and even burnout for physicians. In fact, some physicians have delegated much of the process to their patients. They want the patient to experience what their healthcare insurance company subjects doctors to on a daily basis. If your doctor asks for your help, you may find yourself sitting in on a long, difficult phone call with your insurance company, receiving a faxed prior auth form, and trying to fill out that form with various billing codes and justifications for why you should be allowed to get the health care that your doctor has ordered for you.
Enrollment in a health insurance coverage plan turns patients into rats in a maze.
Not unlike rats, doctors, hospitals, and “consumers” (that’s you and me) must run a maze, full of dead ends, of administrative demands, including:
a host of forms, especially billing forms, that defeat even those most ardent and persistent in trying to deliver necessary services and be paid for doing so;
patient care half the time of doing ‘paperwork’, especially for the monster called the Electronic Medical Record, built for billing more that quality care;
physicians, hospitals, and subscribers (what we who buy health insurance are called) mercilessly going hat in hand for insurance “approvals” to pay for necessary (and continued) treatment, which we allegedly are paying for with our insurance premiums;
and central to all this elaborate corporately designed runaround is that the insurer always wins (like in a casino). You know who the losers are.
Why has this been allowed to continue? What ever happened to health care reform and the affordable care act? Citizens of other civilized nations get health care coverage for free. Yet, the US health system is more complex and expensive than ever, putting many people into medical debt with outrageous, unaffordable medical bills.
For Medicare and Medicaid patients, the goal is to entice them into various HMO plans during open enrollment. Each health insurance plan makes attractive promises to lead consumers into the trap of signing up. “No drug copays. No doctor copays. Free rides to the doctor.” Who wouldn’t want all of the benefits promised, just for signing over your life to them?
We as patients are unwilling victims of an insurance company that lives or dies by whether it turns a profit. The health care they dole out reluctantly is the minimum that they are required to provide by law. What about the free medications and doctor visits, and free transportation?
Just about all of the older generic drugs are covered (because they are cheaper); brand or new medications are taboo. By the way, buying generics yourself, without insurance, would only have to cost you a few dollars. Your doctor’s office is swamped, you can’t ask them for help that will abuse them.
Left unchecked, the health insurance industry has ballooned out of control, raising healthcare costs, and restricting access to treatment. Their gain, however, is our loss.
Which is why, for well over 10 years, the US federal government has tried to protect consumers from insurance corporations siphoning all they could from direct patient care and into their pockets.
What is MLR, and why is it so important?
Have you heard of the “medical loss ratio (MLR)”? The MLR is the foggy term for how much money insurers may take from paying for the direct medical care, and apply it to pay for the costs of running their business and profit, their first and foremost aim.
The MLR is expressed in a percentage, typically 20% what percent of the insurance company’s earnings it may spend for administration, marketing, and profit. That’s 20% ‘overhead’, if you will. Usurious and largely hidden from you and me. It’s why even during the Covid pandemic, health insurers made profits, when those providing patient care generally lost money.
The best rendering I have seen of this preposterous, shameful pocketing of money away from patient care was in the film, “As Good As It Gets (1997)”. We are Jack Nicholson and Helen Hunt who need to get our needed medical care. Cheers for them and boos for their corporate misanthropes were heard in many a movie theatre. By the way, Nicholson and Hunt won an Academy Award for Best Actor and Best Actress, respectively.
We have good reason to hate corporate, for-profit, healthcare insurers. Without a shred of evidence to support their actions, they will continue to screw those who pay for health insurance (you and me), and the doctors and hospitals that care for us.
The measure of a society is how it treats its most vulnerable. That measure applied to the health insurance industry is maybe a D-. We do not, yet, have a ready, swift, and effective means of protecting our lives from the corporatization of American healthcare. The path there, however, is provided by staying true to our moral compass, not going it alone, finding others in the same predicament (and there are may), and unrelenting pressure on those who buy threadbare health insurance (which ironically is principally major corporations and federal and state governments).
Does the Big Tobacco settlement give us hope and a ‘how to’? Or the Opioid Epidemic’s massive litigation having been fueled by Big Pharma? No less might do the job of putting medical care decisions back into the hands of doctors, hospitals, you and me.
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Dr. Sederer takes aim at the “…corporatization of American Healthcare.” Where profits eclipse patients, administrative waste and burden are vast, and we medical consumers regularly are dismissed or overcharged.
If, indeed, there is the possibility of our creating a more just and beautiful world, Caught In The Crosshairs of American Healthcare takes us there, like riding a luge down a steep serpentine ice track, arriving victorious, stronger and wiser in the end.
Read this book. You won’t be disappointed. Indeed, you will be greatly edified.
Eve Konstantine MPH, Founder/CEO of The Georgetown Coaching Partnership, and Social Impact Investor.