close up of person holding pen

close up of person holding pen“I spend all my time arguing with insurance companies and telling doctors they’re pansies,” said my friend S.

She works in the business office of a self-standing New York radiology center, and she agreed to give me her  view of rising health-care costs and the health-care marketplace if I granted her anonymity. Because she is so interesting and so passionate — she’s been in the financial side of medical practices for a number of years —  I agreed.

People argue with S. She argues with insurance companies, and stressed (and anxious and sick) patients beg her for help. She works on behalf of the patient, navigating a complex maze of regulations, billing systems and  emotions.

Most of us never get inside of the billing office — and why would we? It’s complicated enough to experience the billing office they way we usually do, from the counter, before or after a procedure, when we’re wondering what the results will be (anxiety!) and how much we’ll have to pay (more anxiety!).  S., on the other hand, lives there.

“I can’t talk to you now — there’s a patient here for an emergency CAT scan and I have to explain to the insurance company or the patient can’t have it,” she said once when we were on the phone.

When we re-connected, the conversation went quickly back to the insurance companies. “We’re allowing insurance companies to dictate health care, through pre-certification programs,” she said, in which the insurance company refuses to pay a bill for a recommended test unless the patient (consumer) has carefully touched all the bases, made all the calls, received permission from the insurance company, before a test is performed, even under duress of illness and anxiety.

“I tell the doctors, they need to get lobbyists to fight,” she said, so they can prescribe what they think is right.

Insurance companies are not her friends.  She seethes when she talks about them.

“What people really need to know is that their benefits have changed — like me, for example,” she said. “I kept my same [name of company deleted] plan. But people are getting hit with deductibles, added co-pays, because it’s cheaper for the employer. But the insurance company doesn’t tell people about the changes — they say ‘it’s not our responsibility if the member does not read their benefits book.’ “

The upshot is that people come to S. in the business office — everybody knows you can’t get anyone on the phone at the insurance company — and they complain to her.

Then she has to explain what the differences are, based on the new plan, and what the patient will pay.

The view from the medical billing office suggests that the insurance company is pushing a lot of charges onto the provider.

Take something simple and small like records.

S. says the federal government requires that paper records must be kept of various events.

Once upon a time, she says, the insurance companies sent explanations of benefits on paper to providers like S.’s practice, so they could store the records.

But of late, she says, they’ve stopped sending paper explanations, instead pushing the burden of printing (hey, add up the paper and the cartridges and the printer wear!) back onto the provider, while the requirement to maintain paper records persists.

Another burden that lands on the provider: the rising co-pay or deductible, and the explanation. The co-pay went to $35 from $25? O.K., but did anyone tell the insured person? Maybe in the middle of a thick benefits book.

And when the insured person learns about the change, who’s there to complain to? My friend S. — she happens to be available, while anybody who’s tried to talk to a live person at an insurance company lately can tell stories about voice-prompt hell.

Next: Why do things cost so much? And why can’t anybody tell me in advance what something will cost?


Jeanne Pinder

Jeanne Pinder  is the founder and CEO of ClearHealthCosts. She worked at The New York Times for almost 25 years as a reporter, editor and human resources executive, then volunteered for a buyout and founded...