My professional experience is completely rooted on the business/administrative provider side of the equation, and I have never worked for a company which provides health insurance. So my understanding of the health insurance world is limited to my exposure from the provider side. Most of my career was as a hospital CEO, but I am now part owner of two small companies. One provides hospitalist services on behalf of hospitals, and the other provides urgent care services directly to the public. There is more to the “out-of-network” dynamic than meets the eye. We have had one real life example that explains further how complicated this world can get. Our hospitalists were fully credentialed by a national health insurance company and had been for years. This same insurance company offers a health insurance product through the web-based Exchange birthed by the Accountable Care Act. Unbeknownst to us – this same insurance company quietly determined that only a small number of physicians would be invited to participate in the network associated with the Exchange product. In the meantime, we are providing needed medical care to patients covered by the Exchange plan, only to abruptly discover that our physicians were classified as “out-of-network”. A representative with the insurance company has acknowledged the error, and has verbally committed to correct the error; but this issue has lingered unresolved for months. In another real life example involving a different national health insurance company: a group of physicians who owned, operated, and practiced at, a small town urgent care center changed their legal structure. The practice changed neither location nor the make-up of practicing physicians. The only thing that changed was the legal entity, practice name, and tax id number. The requisite documentation was submitted six weeks prior to the effective date of the ownership change, and was submitted accurately. We have just entered the 10th month of operation, treated hundreds of patients insured by this company, have thousands of dollars in claims pending, have received written admissions of error by the same insurance company; and yet company officials have still not provided a firm date when the matter will be resolved and the claims will be paid. Many a young physician setting up a new practice has received a rude awakening to the business realities of getting paid. Many older physicians have quietly gone about their everyday practice of treating patients only to discover that they have been arbitrarily excluded from participation in a mysterious network established by an insurer. Within the complex and imperfect health care industry, there are certainly examples of malfeasance, neglect, and malpractice among some providers of care. But the majority of physicians simply desire to practice good medicine and provide excellent care to their patients. And it is a well- documented fact that the majority of physicians are extremely frustrated with the business of medicine. There are significant challenges associated with the private practice of medicine that simply are not found in any other arena. The system is flawed and in need of dramatic change. But the culprit is not so readily discerned as one may imagine, nor as certain articles may imply.
Posted on: Fri, 03 Oct 2014 16:05:17 +0000
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