Health Insurance 101-5 “Adjustments”

When an insurance company uses the word “adjustment”, they mean the discount they have “negotiated” (dictated) with your “provider” (doctor, pharmacy, hospital, nursing home…..).  This is the amount of the charge that they are not going to pay.  If the “provider” is “participating”, they cannot collect this money from you.  If they do not participate, they can collect this money from you. 

Generally speaking, the doctor had nothing to say about how much the discount was.  If the group is large enough, or if they are the only group in town, they can cut down the discount a bit.  If the insurance company is powerful enough (think Medicare), this is not possible.

Random Acts of “It’s not my job”

There are lots of days when I do things in my office that are really not my job.  I’m sure other doctors do the same thing.

I have a long time patient that I see quite frequently.  I have been trying to convince her that blood sugars “around 300” are not normal.  I had her do a urine test recently that was positive for alcohol!  I freaked out, until the lab asked me “Is the patient diabetic?”  It seems that sugar in the urine will turn to alcohol and make that positive.

I convinced her we needed to check her HgbA1C last visit.  This is a test of how much sugar is stuck to your red blood cells.  The real name for it is glycosolated hemoglobin or hemoglobin A1C.  Hers was almost twice the upper limit of normal.

So today, I, the gynecologist, spent almost two hours with this nice woman.  I first explained why she needed to get her sugar under control.  I want her to live for a while longer.  Then we went over what medications she used to take, and I wrote prescriptions. 

Then my patient said she was having problems with her breathing.  She has chronic bronchitis with an allergic component.   She hasn’t been able to see the “clinic” about this, either.  We went through all the different medications for this, looking up prices at the same time.  You see, she also has no insurance.  Since these are medications I don’t use all the time, I have no idea what they cost.  I was enlightened, to say the least.

Mrs. Train Wreck said that her previous “clinic provider” had told her that she could stop all her diabetes medications since her blood sugar was normal.  I’m not sure who made the mistake – the patient or “the provider”.  Since she sees a different person every time at her “clinic”, never has a scheduled appointment, never gets any continuity of care and nobody explains anything to her, it is entirely possible that someone did say something along those lines.

Remember, though, the “clinic” care is free. 

Health Insurance 101-2 “Participating Provider”

There are two parts to this one.  The first is “participating”.  This means that the insurance company has a contract with someone or something.  The insurance company has agreed to pay directly to this “provider” in a “prompt” fashion.  In return, the “provider” agrees to give the insurance company a significant discount on the charges.

Basically, the insurance company threatens otherwise to wait forever and/ or pay the patient for the service.  Then the “provider” has to try to get the money from the patient.  However, many patients think that the check from the insurance company is money for them to spend.  This is especially true if it is a large amount of money.  The “provider” may be taking payments for years.  The “provider” benefits by getting the check directly from the insurance company. 

We all know that it is corporate blackmail, but nobody can actually prove it.  The insurance company will say that they trust their clients to bring the check directly to the “provider”, and the “provider” must take that risk if they don’t want to “participate”. 

The second part of the statement is “Provider”.  What is a “Provider”?  In health care talk, this can be a pharmacy, a hospital, a home health agency, a chiropractor, an optometrist, a physical therapist, a nurse practitioner, a physician’s assistant, a nursing home……. and maybe a physician.  I didn’t spend eight years in training after college to be lumped with all of these other “entities”. 

Health Insurance 101 - 1 "Usual and Customary"

I find there are a lot of terms that insurance companies use that are confusing to consumers.  As someone who has been dealing with them for many years, let me give you the doctor’s version of some of them.  I look forward to your comments.

“Usual and Customary Rate” is what the insurance company decides it wants to pay.  It has nothing to do with what the doctors in the area charge or expect to get paid.  Of course they represent to the patient that the doctor is charging more than s/he should.  Insurance companies also tell patients that they are not responsible for any more than what the insurance company determines is the UCR.  This may be true if the doctor participates with the insurance.  If the doctor is not a “participating provider” (Health Insurance 101-2) you are responsible for whatever the insurance doesn’t pay.   

Insurance companies are not allowed to set a doctor’s charges.  They can tell us how much they are willing to pay.  We can decide whether or not we are willing to work for that amount of money.  If not, we don’t participate.