How do doctors deal with insurers? I met a doctor in an online group and we struck up a conversation. Her views were so interesting that I asked her to join me in a series of conversations for ClearHealthCosts. She is a D.O. (Doctor of Osteopathic Medicine) in private practice who also has a leadership role in obstetrics and gynecology at a Midwestern hospital system. She spoke on condition that we not use her name. Here is our fourth conversation, lightly edited for length and clarity. Links to the first four are at the bottom of this post.
JP
We hear a lot from patients about how they hate their insurance companies. But we don’t hear a lot from the doctors about that. What’s it like dealing with insurers? How have things changed over your career?
Dr. X
From our side, they’re not partners in the health care realm. Sometimes they play by the rules, but a lot of times they throw up roadblocks.
Insurance is getting more and more expensive for the patients, and I feel like they’re getting less and less benefit for it. I was trying to think earlier today, before we met, about good things about insurance companies. Their prices are astronomical. What they’re giving to our patients, their customers, is so substandard, it’s really difficult to watch.
Cancer treatments denied
JP
Give me a specific case of substandard performance from an insurance company.
Dr. X
In the obstetrics and gynecologic space, it’s not as bad as in other specialties, like in oncology. I don’t know how those people deal with the insurance companies they have. They’re taking care of patients who are very, very ill, oftentimes need very expensive medication, that there’s not a generic equivalent, because a lot of the new cancer drugs are just developed. It’s one thing when you have to go through prior authorization for your hormonal treatment, but it’s a whole nother thing, when you have to go through a prior authorization for your cancer treatment.
JP
So, a treatment like a medication, like chemotherapy, or a surgery, is denied?
Dr. X
It can be, or you need to do prior authorization. The doctor shouldn’t have to deal with that. The patients shouldn’t have to wait.
JP
The insurance companies’ argument, of course, is that they are saving money and saving patients from unnecessary treatments.
Dr. X
Yeah, they will say that, “Oh, this isn’t the standard of care.” They have their own medical advisory people who are incentivized to keep the treatment cheap. It’s ridiculous. There’s been stuff in the media about the people who do peer-to-peer reviews who aren’t even a peer. And then you have to justify your treatments for the patient. That’s kind of terrible.
JP
Denying somebody treatment might mean that they get worse or die, right?
Dr. X
Yep. It would be interesting for you to talk to an oncologist who was thinking about that because I’m sure that they could give you a plethora of anecdotal experiences with this.
Payment delays
JP
Do the insurance companies pay you on time?
Dr. X
It depends who you’re talking to. Sometimes. Some of the better ones do, and they pay relatively promptly now, with the money all being electronically moved around.
UnitedHealthcare, we’ve had problems with them paying on time, wanting medical records for everything for a time. They don’t do it really anymore.
But anything that you had a “25” modifier [medical code] on? This is when you see somebody for, say, their annual exam and Pap smear, a well woman preventative care visit.
They come in and say “Well, I’m having menopausal symptoms, this irregular bleeding” – that automatically generates a modifier code. You can do one of two things: You can have them come back to address their problems, which you’ll get paid more for, or typically what we do is I just take care of it at that time.
I know I’m gonna get paid less, but I don’t have places to put these people. I’m booking many, many months in advance for an exam. So I just see them, and then I put a “25” modifier onto their preventative care bill and charge for the diagnosis codes.
For a time, United Healthcare was making us give records for any patient that had a “25” modifier. It was ridiculous. That’s kind of an easy throw-up-a-roadblock kind of disadvantage, to disincentivize the practitioner from charging what they should be paid for the services that they’re rendering.
Another thing – a lot of times you go somewhere and they say, “If you pay cash, it’s X amount of money, but we’re charging you an extra 3% if you pay with a credit card or FSA card.” So many people now pay their personal responsibility that way. There’s usually about a two and a half to three and a half percent service charge for that.
We were going to pass that along to our patients. But you can’t do that if you’re contracted with the insurance companies.
Approved, but not paid
JP
I heard somebody else was talking about a delay in pay after prior authorization that was described as “prepayment review.” The report was the procedure had been authorized prior, and then when it came time to get paid – maybe that’s what you’re talking about the extra medical records. The term of art was prepayment review. “Yes, it was authorized, but we’re saying no.”
Dr. X
Yes. That’s for surgeries. Even when you pre-authorize a surgery – which some you do, and some you don’t – my office will call them and get a pre-authorization number. They’ll even do that for things like a CT or an MRI. There’s like a disclaimer that, even though we approved it, that doesn’t mean it’s necessarily approved.
So why bother? Right?
What patients can do
JP
How can patients help you out? In this case, is there something that patients can do to make your life easier?
Dr. X
What can they do? Vote. Vote for people who are not going to support this. It’s hard, though, because the insurance lobby is so ridiculously powerful.
How else can they help? A lot of times, if the insurance company is giving me a hard time about paying for something, I will tell the patient to call the insurance company and complain, because they don’t care about me. They look at me, and they think “we have 27,000 other doctors,” But sometimes they listen to the patients a little bit more.
We actually, when we were renegotiating a contract with one of our insurance companies, it was a pretty tough negotiation. It took a long time, and they were just jerks about it.
We sent out a letter to our patients that said, “We are currently negotiating with X insurance company. We are not asking to be paid an extraordinary amount of money. We are wanting them to pay what most of the other insurance companies are paying.”
They were probably about anywhere from 20% to 40% below. We were thinking “you may as well work smarter, and get rid of the insurance companies that are the poor payers.”
But we thought we would try and negotiate first. So we sent out this letter to our patients to say, “if you have a chance to call your insurance company, or if you have a chance to talk to your HR departments, and say, hey, this insurance company is really difficult for my physicians to deal with.”
I’m not sure if that made any difference, but I know, some people did call. I have some patients who are the heads of pretty major corporations in the area. Hopefully, that landed on some level. They came back and gave us what we wanted.
So that was really good. I do think our patients were helpful.
Patients have power
JP
Patients think that doctors have all the power. When patients come to us and say, “the insurance company wouldn’t pay for it,” we usually say “maybe your doctor has to make a call to the insurance company, or maybe your HR department needs to make a call to the insurance company, because the employer is the ultimate payer, right?” Yeah – patients. I think I speak for millions. We feel like we have no no power.
Dr. X
I think they have more power. I think the companies definitely have more power. A corporation that is a major employer in our area negotiated with an insurance company. And I think I’m pretty sure that somebody very high up in that corporation kind of rattled their cages and all of a sudden, they got what they wanted. It’s not like you’re asking for the moon, you’re just asking to be paid, parity to what other insurance companies are paying. But they still lowball people. It’s ludicrous, right?
JP
Does this happen with medications also? You may know less about that. Because more on you’re more on the procedure side?
Dr. X
Kind of half and half actually. What we see it so much with is hormone replacement therapy.
I’ll give somebody a script for vaginal estrogen. And then she will come back and say, ”I can’t afford this. It’s $200 for this prescription.”
Why should it be $200? It makes no sense. Especially for drugs that are not generic. There’s an example of a name brand medication that I use very frequently that is far superior to the generic. It can be used to help women with painful periods or irregular cycles.
On the face of it, it looks like it’s pretty much the same, but in actuality, it works by a different mechanism.When using it only for its birth control effects, it is far superior in its overall effectiveness because it suppresses ovulation, which the older form of the medication does not. I can’t tell you the amount of prior authorizations you need for that, and they deny it. It’s a birth control pill. It’s ridiculous.
Price-shopping for medications
JP
Do you ever send patients for prescriptions with generics to a Mark Cuban Cost Plus Drugs?
Dr. X
Oh, yeah. All the time. I love Mark Cuban Cost Plus and GoodRX.
JP
For me personally, GoodRX is less good.
Dr. X
It depends. I’ve done it for my mom, where I shop on both. With GoodRX the prices fluctuate.
JP
Switching gears, I guess, you know, when we look at this question, we want to understand that the basic goal of the healthcare system is to make people healthier. If the insurance companies are not doing that, then shouldn’t somebody be pointing that out?
Dr. X
I think it’s starting to come out in the media. Our health outcomes are worse for as much money as we spend relative to our population. So it’s there, but nobody’s really doing anything about it.
What’s interesting to me: If you check the charges for the hospital, when somebody goes in with private insurance versus government insurance, the private insurance really does subsidize, I don’t know if it’s true or not, but the hospital administrators seem to make a good case for that – that private insurance really subsidizes what Medicaid and Medicare pays to hospitals. Just to say, you know, single payer health care is the answer.
Tax dollars
JP
I think I’d have to see the numbers on that. Because the truth is that the insurance companies are racing into Medicare and Medicaid. Much more of their business is subsidized by tax dollars. In fact, Humana completely abandoned the employer and individual market to embrace only taxpayer supported programs.
Dr. X
Oh, you’re kidding. They don’t write private insurance anymore?
JP
No. And if you look at the numbers for United Healthcare, for example, their Medicare income dwarfs the private market. It’s a weird thing, because most people feel like the insurance companies are making a lot of money off of individual marketplace and employer policies. Sure they are, but they’re making much, much more on Medicare Advantage, and also Medicaid. Follow the money. Like, where’d the money go? I’ll send you a link to a story that documents the whole thing. It just became this runaway train. The idea that private insurance is subsidizing Medicaid and Medicare is no longer true.
Dr. X
My mom will talk about her friends – one friend of hers who has Medicare Advantage who thinks it’s the be-all end-all. But wait till she gets sick, and she can’t get anyone to see her. And she needs pre-authorizations for everything. Wait till she needs physical therapy and there’s a X amount of copay every for every visit with the therapist.
JP
There are so many unfortunate things about it. One of the most unfortunate things is that people towards the end of their life, they may not really understand what is happening.
Dr. X
I had to sign my husband up. I do the insurance and our family, and he turned 65. So I’m like, OK, you’re going on Medicare, because it’s costing me $1,300 a month because he works for himself. So for him to get on Medicare – it was so complicated. And you know what I did to figure it out? I went on TikTok.
What can be said or done?
JP
The ultimate question, of course, is, as far as insurance patients, doctors, the healthcare system in general, legislators, regulators, who also have parents who may be on the wrong end of the Medicare Advantage thing – what can be said or done that would make any difference?
Dr. X
For elders, I think going back to regular Medicare, and having it funded adequately. It’s not transparent. And as a result, I think a lot of older people are getting themselves into something other than what they intended. And from what I understand, it’s very hard to get out of. It just seems crazy that it’s hard to get out of it. I just can’t believe that our government entities aren’t helping with that.
What would really be better is if you could do Medicare, for all, a single payer health system, but you would have to go back a step. And another step and another step.
My youngest just matriculated into medical school. It’s $70,000 a year. Medical school should be like it is in Europe – it should be free. And then if you were in a single payer health system, you wouldn’t need to make, you know, X amount of money in order to pay off loans that are equivalent to a mortgage on a very nice house. If you want to take loans, and most people need to take loans, the interest rates are exorbitant. I’m gonna say, like, 9 or 10%. I mean, they’re ridiculous.
I don’t know. It’s not providing better health care for us. It’s not doing things efficiently. I don’t know if just canceling it all is the right answer either. But there’s got to be something better than this, you know?
JP
Yeah. It’s a mess.
Here are other parts of the series:
What patients don’t know: Dr. X talks (Part 1 )
TikTok childbirth and less personal access to doctors: Dr. X talks (Part 2)
More women gynos, but women’s health issues are getting worse: Dr. X talks (Part 3)
Behind the scenes at your doctor’s office: Dr. X talks (Part 4)
