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Reader Comments on: Reimbursement for New Technologies: The GERD Maze Is Not Patient-Friendly See reader comments on this article and provide your own.
Readers are encouraged to respond to George Lundberg, MD, Editor in Chief of The Medscape Journal of Medicine, for the editor's eyes only or for possible publication as an actual Letter in the Medscape Journal via email: glundberg@medscape.net
To the Editor,
I read Dr. Schwaitzberg's letter in regard to the problems with payment for patient examination/evaluation using new technologies and agree with his recommendation that changes need to be made in how decisions are made with respect to insurance payments. I also agree with his statement that the insurance companies appear to take the position that if they make the claims process difficult enough, doctors will stop trying to get paid. However, both of these statements are not broad enough. If Dr. Schwaitzberg thinks it is hard for doctors to get paid by insurance companies when, generally, they have staff who are knowledgeable about the insurance billing and reimbursement maze, he needs to view the problem from a patient's perspective.[1]
On 3 occasions I had my insurance company tell me that I was responsible for an emergency department (ED) copay even though my policy waived the copay if I was admitted to the hospital, and in each of the 3 cases I was in fact admitted to the hospital.
On the first occasion, I went to the ED suffering an anaphylactic reaction secondary to ingesting food that apparently had been cross-contaminated with shrimp. Despite use of my EpiPen, treatment by the EMS [emergency medical services] crew, and treatment in the ED, my symptoms reoccurred while in the ED. As a result, the ED doctor had me admitted to the hospital for further observation. I spent the night in the ICU [intensive care unit] because that was, apparently, the only monitored bed that was available in the hospital. Fortunately there were no further incidents and I was discharged the next morning.
On the second occasion, I went to the ED with what turned out to be an obstructed small bowel. Since less than a year previous to the incident, I had a colectomy with J-pouch resection; the doctors at my local hospital believed that I needed to be transferred to the tertiary medical center where the procedure had been performed because the risk for complications was beyond the level of care at the local hospital. I was transferred by an ALS [advanced life support] ambulance crew and received IV [intravenous] fluids and medication during the transport. At the medical center the diagnosis of obstruction was confirmed and fortunately was resolved without further surgery.
On the third occasion, I went to another ED with significant chest pain. Without going into specifics given my age and other risk factors, the possibility of an MI [myocardial infarction] was significant. I was treated in the ED under the usual MI suspected protocol and admitted for further evaluation and observation. I was discharged 2 days later without any significant findings.
When I received notice from my insurance company that I was responsible for the ED copay in the first and third instances, I was told that I had not been “admitted” to the hospital. I assumed that there had been a clerical error by the hospital and contacted the billing office, at which time they assured me that the claim had been submitted properly but that the insurance company determined that I had not been admitted to the hospital. I ended up in a revolving door between the hospital and the insurance company, each stating that it was the other's determination that even though I occupied a bed, in the third instance for 3 days, I had actually been an “outpatient.”
When I contacted my insurance company in regard to the second instance, I was told that I was responsible for the ED copay to the original hospital because I had not been admitted to that specific hospital. I explained that the hospital would not admit me due to the potential for complications beyond their ability to provide service. I was informed that I should have gone to the tertiary care facility originally (an hour's drive vs 5 minutes to the local ED), and had I done that, the copay would have been waived because I would have been admitted through their ED.
I am an educated individual with both a legal and medical background, and I was not able to break through the red tape and bureaucracy to have the insurance company do what the plain language of my policy said was their obligation. I can only imagine how quickly less educated individuals or elderly patients would have given up and either paid the bill or, like many Americans, let it go to collection because of the inability to pay.
The regulators of insurance companies not only have to make the insurers more responsive to the plight of doctors by opening up their decision-making process, but they need to also ensure that the insurance companies do not bury their responsibility to the patients under so many exclusions and footnotes of the “Master Agreement” that the information supplied to the patient is useless when it comes to making choices about which policy to choose as well as understanding in plain English what services are covered, what are not, and why.
Mr. Fekety correctly points out that the current system is leveraged against both doctors and patients. Too often the current system becomes a clever array of moving targets that drive total healthcare cost skyward and then work against those seeking care or those dedicated to providing it. Clarity, transparency, and simplicity (as well as common sense) need to be the hallmark of healthcare for our future.
