A view from the other side


Fam Pract Manag. 2008 Sep-Oct;15(8):14-18.

I enjoyed reading the article “Working With Insurers: A View From the Dark Side” by Lee Buttz, MD, MBA, in the July/August issue of FPM. I too have been a medical director for a major insurer, and at that time I would have agreed with many of his suggestions.

However, I am now back in private practice and have a perspective from the other “other side.” On an average day of seeing 20 to 25 patients in our internal medicine practice, we receive five to eight denials from multiple insurers for various services. All of these denials require faxed responses, letters or phone calls. Rarely can anything be cleared up with a single response; many denials require multiple requests that quickly overwhelm our small staff. Dr. Buttz's pearls may work in an ideal world. However, in the real world of daily practice it is difficult, if not impossible, to run the insurer gauntlet.

The final result is that patients do not receive services they require and their optimal health is jeopardized. I was also once guilty of seeing through the myopic lens of the insurer. Perhaps it's time insurers came into our world to better understand our frustrating attempts to obtain legitimate care for our patients.

I applaud Dr. Buttz for his attempts at making my practice life better, but I wonder if he knows the circumstances that are closing down primary care offices. I saw 22 patients each day in my private practice, and my reimbursement should have been contractually between $55 and $72 per visit. Payment was denied several times daily, however, and not for the reasons noted by Dr. Buttz.

I recently closed my office in California because of deteriorating payment from insurance companies. Claims were often denied for unsubstantiated reasons including “not an active member” (although the patient was active), “claim filed beyond the time allotted” (although it was filed within days), “not a covered service” (although the service was indeed covered), “improper member ID” (although the patient had a proper ID) and others.

Before anyone takes the side of the insurer, remember that the addition of a full-time re-biller is not a position a primary care office can afford. It is true that the doctor could personally call the insurance company with each erroneous reason for nonpayment, but then who would practice medicine? I left a town of 8,000 people without a physician rather than watch my income go from inadequate to worse. The role insurance companies play in ruining primary care in America is an entirely different topic but one that is far more worthy of an article in FPM.

Author's response:

I appreciate the comments written about my article on working with insurers. Both readers describe the frustration they feel with the current American health care system. Having worked both as a practicing physician as well as a medical director at an insurer, I understand the problems resulting from miscommunication and lack of information.

Clearly we as physicians all have an obligation to work to improve the system for our patients and our providers. The purpose of my article was to help educate physicians so as to develop a better understanding of how insurers approach the review process. My hope is that this understanding will allow physicians to reduce the administrative burden of insurance coverage verification while we all work for a better tomorrow.


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