Archive for category Insurance Coverage
My dad’s wife called to ask if I could see a friend of my brother’s. This 30 year old woman had been “put through the ringer” by her HMO dermatologist. He looked at her nose diagnosed a “pre cancer” and treated her with freezing. Then he put her on a cream. The “wart” is still there and she can’t get in to see the doctor (actually a physician’s assistant) for 2 months.
Welcome to capitation medicine.
This evil creation of your local managed care plan pays a doctor a fixed fee to take care of a group of patients. It is sold to the doctor as “money for nothing”…no not the Dire Straits song. The doctor then is paid nothing additional to take care of you. He has an incentive to ignore you (as he keeps the money) and none to care for your issues. The amount paid per patient is pretty low….like a couple of dollars. The doctor only makes money if he doesn’t provide much care. This is the evil part as far as I am concerned.
I have been very hesitant to deal with capitation medicine. This woman’s health insurance coverage will pay nothing toward my involvement as I am a non-Provider. That’s what you get with mangled care.
John Di Saia MD
Originally posted 2005-11-07 09:17:00.
We have discussed health insurance games before. They commonly entrap doctors and patients in red tape and denials of care and payment. The public only occasionally becomes involved in the situation when they are affected directly. This time 20,000 Orange County Blue Shield HMO patients are involved, so there is interest:
Nearly 20,000 Orange County HMO patients are caught in the middle of contract dispute between Blue Shield of California and Monarch Healthcare, an Irvine-based medical group with more than 2,000 doctors. Starting May 1, Blue Shield will no longer have a contract for its HMO patients to see Monarch’s network of doctors across the county. Yet the insurer alleges that patients are being falsely told they are losing their doctors this month, and in a few cases, have been denied care.
Health care contracting is a complex maze. HMO patients generally buy their insurance from one of the large health care insurers such as Blue Shield. Few if any doctors can bill an HMO directly though. The usual arrangement is for the large health care insurer to sell (yeah, sell) the responsibility of the care of the patients in groups to an IPA (Independent Practice Association.) The kicker is that the large HMO insurer gets to keep up to 30% of the premium payments in this sale. That amounts to less money available for the care of the patients! Physicians must join an IPA to get paid on HMO business. The IPAs pay poorly for specialty services, so many sub-specialists (like Dr D ) do not deal with them.
The bottom line here is that for HMO patients to get regular care they need to maintain a relationship with a doctor who is a member of an IPA that is contracted to their HMO. They essentially enroll in that IPA to set up the linkage. When the chain is broken, the patient finds him or herself without a doctor. In this case that happened due to a contracting dispute between Blue Shield and Monarch IPA.
John Di Saia MD
Patients and families usually don’t understand the often sneaky ways health insurers use to discourage surgeons from working on their insured. When your insurance representative says the company will cover a procedure, it does not mean they will pay reasonably or quickly for it at all.
Today I saw a patient’s husband at a wound care hospital at which I see patients. He was favorably presenting his wife’s “Medicare PPO” insurance. I have dealt with these before. They have never been all that great.
For the sake of argument, we called the insurer to inquire about their rates. They require pre-approval to operate and pay 70% of Medicare rates. In essence, to operate on such a plan is to operate at a loss. even if they don’t play games about paying after surgery which is also quite common.
I will suggest that the patient seek a provider physician to perform her surgery.
John Di Saia MD
Originally posted 2011-04-11 07:30:26.
I am a 58 year old male. I had a heart transplant in 2008. The steroids and immune suppressants have wreaked havoc on my body, internally and externally. In addition I was unable to exercise for the 5 years that I had Idiopathic Dilated Cardiomyopathy. My problems now arise from the above. My need is for plastic surgery to eliminate this apron of skin on my lower abdomen and to tighten the stomach muscles. My back is constantly going out because of the atrophy in the stomach muscles. My butt is drooping too but I can live with that. Additionally, I have a hernia in my upper abdomen on the right side since the transplant. It is painful and needs to be addressed. I also got hernias under my eyes. None of this existed before. I am on disability so my funds are limited. I do have Care Credit with zero balance but I don’t know if Medi/Medi covers any of this. If we can come to some sort of deal I also need platismacosty, from the moon face on the drugs. Most of the side effects are gone and this is what I’m left with. None of this is cosmetic for cosmetic sake alone. Consider my needs and maybe I could be in a commercial for you or do some other ad for you to defray part of the cost.
While I feel for your situation realize that you are a complicated patient in whom major plastic surgery might not be the best idea. Even if funds were not in short supply, you constitute very high risk for complications after surgery. With your immunosuppression schedule, these may develop into life threatening problems such as wound infection, tissue necrosis, and/or blood borne infection. It is also questionable regarding the degree to which surgery may relieve your back pain.
While you make the case that your surgery is medically-indicated, it is very difficult to prove this to the satisfaction of insurers in this market. I wish you the best but would advise you against seeking large scale surgery due to your medical status.
John Di Saia MD
Originally posted 2011-04-29 07:30:58.
People are often surprised that a plastic surgeon would care for Medicare patients under that coverage. Well of course we are not doing cosmetic surgery as a Medicare benefit. That would be illegal.
What do Plastic Surgeons do for the Medicare patient:
Skin Cancer Removal/Reconstruction
Breast Cancer Reconstruction
Wound Care and Reconstruction
If you have regular Medicare plus or minus a secondary, the process is pretty straight forward. If you have signed over your benefits to an IPA, you are limited to IPA member doctors only and need pre-approval to even be seen by a specialist. I deal with regular Medicare patients every week.
John Di Saia MD
Some Cigna PPO insurance plans do not cover breast reduction specifically. We saw a patient in the office and tried to obtain pre-approval for a breast reduction. Medical necessity was clearly in play in this slender 5 foot tall woman with size EE breasts. The insurer’s representatives did state however a month into the process that her insurance plan specifically excluded the benefit of breast reduction.
Watch your plan specifics when you sign up for that health insurance. When you’d like to use it it might not be there for you.
John Di Saia MD
I received the EOB (Explanation of Benefits) from a case I did in the emergency room a while ago. EOB is certainly a misnomer here as the insurance company applied the amount of the bill in its entirety to her deductible.
Patients are often surprised when their PPO plans pay nothing and proceed to get angry at the surgeon that came out on the weekend at night to put their face back together. In this case, the young lady split her lip open surfing.
“Don’t blame me for your insurance company woes. You signed up for that policy.”
People often don’t understand the stipulations of their insurance plans. They just know that the plan costs them money; frequently a lot of money considering these plans pay out so little. My belief is that insurance plans are often constructed in a confusing way so that people don’t know what they are getting themselves into.
A few basic points:
“Deductible” – This is the amount you agree to pay (usually yearly) before the plan pays out a dime. Patients frequently increase this number to bring their premium down.
“POS” – Point of Service – These plans frequently have both HMO and PPO aspects allowing access to Out Of Network providers but better coverage for in plan providers. These policies are hard to find these days.
“Co-pay” – More of your money that you agree to pay at office visits on top of the deductible.
“Provider” – A doctor that agrees to let the insurance company regulate his fee structure. I was collecting about a third of my charges when I was a Provider for more insurers. Can you say “revenue negative?” Your share of cost will be less with a provider doctor. Then again as a provider doctor I was losing money and had very little time to spend with my patients.
Generally as Co-pays and Deductibles get larger, the premium gets smaller. Then again you are agreeing to less insurance really. Beware that which you sign as this seals your fate.
John Di Saia MD
Originally posted 2005-09-13 19:47:00.
Medicare HMOS confuse patients for a living. They basically seize your Medicare benefits and sell the responsibility for your care to an IPA, which then controls your access to care.
I saw a Medicare HMO patient who had his care contracted to ADOC, the Affiliated Doctors of Orange County. I was asked to see him in the wound care hospital where he was staying with large wounds in his leg. The doctors taking care of him wanted skin grafting to facilitate healing of these wounds.
In order to expedite a patient’s care, the better IPAs will agree to fund care by non-contracted doctors at an mutually agreed upon rate. ADOC is not such an IPA instead choosing to transfer the patient to a nursing home without surgery to delay the cost of surgery. They actually sent him by ambulance to the office of a provider doctor within days of my first inpatient visit with him.
ADOC prefers to deal with the patient’s wounds at their convenience as an outpatient when a contracted doctor can get to him. This delays his time to skin grafting for weeks to months. In my opinion, this defines poor quality care. If they were your wounds would you rather have them dressed with gauze for the additional time or have the repaired before you left the hospital?
This is why your Dr D is not an ADOC member.
Sneaky HMO Tricks:
ADOC used two Sneaky HMO Tricks here:
(1) Transfer the patient out of the hospital before surgery happens even if it delays or denies the patient care.
(2) Without so much as a phone call to the consultant on the case, send the patient by ambulance for an office visit with a provider doctor.
John Di Saia MD
Recently a patient came to the office with the need for a complicated breast reconstruction after finding that she had a Brca gene. She had already had breast surgery and radiation therapy and now was looking at complete breast removal and reconstruction. She was pretty clear that she had no money to pay for anything, but was waving around her Blue Cross PPO card like it was a VISA.
What was she even doing with a PPO card?
When patients sign up for PPO insurance, they are basically saying: “I am willing to pay more, but I want choice.” PPOs generally allow patients more selection with coverage for doctors (both in and out of network,) but patients pay a higher share of cost for that care. When you are on the cusp of expensive breast cancer surgery, a PPO card means you are going to pay thousands if not tens of thousands of dollars by the time you go through the multiple operations to remove and re-build your breasts.
HMO plans on the other hand have limited doctors (less or no coverage for out of network) and hurtles to care, but once you get in for that care, it costs you less.
EPOs tend to be somewhere in between. Now with this being said, each plan by each carrier can be quite different. Plans often have multiple deductibles for in and out of network doctors, facilities and hospitals. You really need to look into your plan before you sign up for it. But if you are looking to pay little or nothing over and above what your insurance pays, you should be looking into HMO coverage most often.
John Di Saia MD
An excellent article on Capmag.com comes to the wrong conclusion but summarizes many of the points of argument very well.
I disagree with the conclusion that government-based health care is the best answer.
A few alternatives:
(1) Limit liability costs via tort reform.
(2) Unmask insurance company profits (executive salaries) to let consumers know they have been had. I love the recurring case of insurers saying they are broke and awarding executives with millions in bonus cash at the same time.
(3) Burn the Medicare code. It should not be a game trying to get paid for work that has already been performed. Consider paying physicians in tax breaks for non-compensated care including the care of the disabled and indigent. Decrease administrative overhead.
(4) Then go back to a first party system with Medical Savings Accounts and insurance coverage in the way of high deductible policies for the remainder.
I have seen and worked in the Veteran’s healthcare system…this is your government running health care. It is costly and inefficient. I would not think it would work on a larger scale. The costs would be enormous.
John Di Saia MD
Originally posted 2005-09-09 20:41:00.