24
Health care as seen from the other side
Clinic office assistant Joan Vest searches for a patient's misplaced medical file at the Spanish Peaks Family Clinic on in Walsenburg, Col.
To view this content, Javascript must be enabled and Adobe Flash Player must be installed.
TEXT OF STORY
Kai Ryssdal: Today we're going to start an occasional series called The Cure. About the remaking of the American health-care system. Where the real costs are. And the savings, too. Up first, the inner workings of a typical medical practice. Did you ever wonder, for instance, what all those people on the other side of the counter are actually doing? And why there are so many of them? We sent Marketplace's Tamara Keith to find out.
TAMARA KEITH: It's one of the first questions a new patient hears when they come into a doctor's office.
DOCTOR'S OFFICE: May I go ahead and copy your insurance card and driver's license please.
These days, dealing with insurance is a huge part of any medical practice. A recent Cornell study found nationwide it costs doctors $31 billion a year to deal with insurance companies. That's about 7 percent of all spending on physician and clinical services.
At Ortho Bethesda, an orthopedic practice in suburban Washington D.C., there are eight doctors on staff, and 14 people in the business office.
SHARISSA DYKE: Hi Rob. My name is Sharissa, and I'm calling to verify medical benefits for a patient.
Sharissa Dyke is an insurance verifier at Ortho Bethesda. She basically spends every day checking whether patients have insurance and what their plans cover.
DYKE: Is authorization required for outpatient MRI?
OFFICE WORKER: No ma'am.
DYKE: And who do we send claims to?
Ortho Bethesda deals with more than a dozen different insurance companies. They all have different systems for filing claims. And each company has a bunch of different plans, each with varying co-pays and deductibles and rules about whether pre-approval is necessary. This keeps the business office busy and irritates doctors and patients.
DOCTOR: She's Aetna, and she had acute injury to her knee a week ago.
A doctor walks into the business office with a patient's chart and a sense of urgency.
DOCTOR: And she needs an MRI to evaluate for a PCL tear. And I'm not sure if her flavor of Aetna needs authorization.
The MRI will help determine whether the patient needs surgery. Sometimes it can take several days and lots of paperwork to get approval from the insurance company. Other times, it's 15 minutes on the phone, only to discover.
OFFICE WORKER: Based on the information provided this particular Aetna member's plan does not require pre-authorization for service at this time.
This drives Dr. Edward Bieber crazy. He is the managing partner at the practice and an orthopedic surgeon.
Dr. Edward Bieber: It's time consuming, it's expensive to our office, and it takes up a great deal of my time that I would like to spend giving care to the patients rather than shuffling their papers.
Bieber says he's never had an insurer deny an MRI, so why all the red tape. But insurance companies say requiring approvals cuts down on unnecessary tests. MRI's cost somewhere between 500 and a few thousand dollars depending on the type. Susan Pisano is with America's Health Insurance Plans, a trade group.
SUSAN PISANO: High-tech imaging is being greatly over used and misused. It affects out of pocket costs for consumers. It affects premiums. It affects quality and safety.
Pisano agrees doctors shouldn't have to deal with so many different billing systems. She says her industry is working on it. Later this year her group will test an online system where doctors can access information and use standard forms for all of the insurance companies in their region.
PISANO: The estimates suggest hundreds of billions of dollars could be saved if everybody is using the same rules.
The American Medical Association, which represents doctors, is trying to get some of that provision written into new health-care legislation.
But that alone won't eliminate a huge source of back-office costs: Dealing with a multitude of insurance companies who each have different rules for which procedures they will cover and how much they will pay. Until that changes, there will continue to be more office workers at Ortho Bethesda than there are doctors.
In Washington, I'm Tamara Keith for Marketplace.
Pages
- ‹ previous
- 1
- 2
- 3
Just got back home after listening to your story about physician's staff having to deal with insurance company payment policies. Interested that the story commented on the amount of costs to physicians. Although valid points, compared to the costs of malpractice to a physician's practice, these costs do not compare, especially when you factor in the cost of defensive medicine such as ordering an MRI of a knee in part because the patient wants one, and can not be convinced otherwise, and heaven forbid the physician does not order one immediately and the patient ultimately is found to have something on the MRI, related or not....Mr. Attorney is never far behind. So let's not forget about tort reform in all this talk about healthcare reform because the 2 are interwined.
I reacently was diagnosed with a "frozen shoulder" or adhesive capsulitis related to a possible rotator cuff injury. It took a over a month to receive approval for a MRI to confirm whether there was a rotator cuff tear.
In the mean time the doctor's office had to use their staff to repeatedly call Aetna and had to resubmit diagnostic information. A further note to this long process was that Aetna contracted out the approval process to another company and then another company contacted me as to whether this was due to a work injury, car accident or a slip/fall at a neighbors! Any way they can work out not paying they will try. One of the leading orthopedic practices in Annapolis Maryland is not accepting Aetna because of their low reimbusement and the practice I am using may follow suit. Help!!!!!!! Is there a solution???????
In 2004, when my mother was 1st admitted to a "major university hospital"; I was very distressed by the STUPIDITY of the administrative systems. Given that PROCESS REENGINEERING was my area of expertise, I wrote a letter to the Chief Admin. Officer of the hospital offering my assistance to correct these problems AT NO CHARGE (i.e., Free Services - I'm happy to help).
I was NEVER contacted (not even a "thank you" for writing).
Since Hospitals assume that they will always get paid (or else keep raising their prices); Where is the incentive to be cost effective? We need a Carrot and Stick Approach to US Health Care, otherwise we're all playing with loaded dice!
I worked for Ingenix, a subsidiary of UnitedHealth group, for three years as a software developer. I worked on a crack team of Java developers who used cutting edge technology to build two huge software systems: ContractManager and iCES.
ContractManager cost $150,000 a seat. It sat in the offices of large physician practices and analyzed the doctor's rejected claims and figure out ways to bleed more money from insurance companies.
iCES sat in the office of insurance companies and analyzed claims using high technology with the intent of finding ways of paying doctors less.
Our shorthand internal way of describing what we did: "Selling guns to the Hatfields and the McCoys."
Having worked for several insurance companies, I must point out that the single payer, public option is the way to go. Right now, providers and payers are having an arms race and you and I are paying for both sides.
Pages
- ‹ previous
- 1
- 2
- 3
