Saturday, July 4, 2015

Sorting Out The Insurance Mess

Where to start? Health insurance for everyone? What a concept huh? And along came a bill that attempted to improve those chances. I was beside myself. I was happy for all those folks that couldn't get medical care.  And then the chaos ensued.
The rollout of President Obama's health care overhaul was a fiasco. The web site was plagued with glitches. Sign up day found millions of people stuck in the fog of the web, floating or frozen, trying to find their way to choices for insurance.
Eventually, after much scolding from the right wing body of our government and Fox News, better known as Faux News, and much heart massage the web site breathed new life.
I breathed a sigh of relief. All is well. 6 million people have health coverage. The left wing of the government broadcast the glee of the citizens that finally had health insurance. The right tried so many times to reverse the decision and get rid of it that they became a joke among the citizens of the USA and still no one told the newly insured their policies would be paying minimum reimbursements to the physicians; the fly in the ointment.

I was still under the impression, and loudly defended the passing of a bill that would regulate the insurance companies and make health care affordable to so many. I was ashamed of the states under GOP governorship that would not accept the Medicaid Extension which would have covered the folks making less then 20,000.00 a year. Oh yes. There is a minimum amount one has to earn in a year to qualify for subsidy. Subsidy is the larger portion of the premium that the government will pay on your policy leaving the insured a small monthly premium.

One could still buy 'outside' the market place but there would be no subsidy offered to those. The cry went up immediately about the high cost of premiums from those whose income was over the limit and did not qualify for the subsidy. Those premiums were going to be steep. People who had insurance didn't understand why their companies were suddenly cancelling their policies and offering them different policies. The truth is those policies held by a lot of workers were the junk policies that had a  ceiling on payments. Once that was reached, your insurance was cancelled and with a pre existing condition you could not buy another insurance policy elsewhere. Insurance companies then and now ruled.

What you ended up with on this Affordable Care Act was the very poor without any help because they didn't meet the minimum income requirements, the middle bunch with subsidy and the upper level with very high premiums. A lot of people fell through the cracks because the governors of the Republican states refused to take the Medicaid Extension money offered by the federal government to cover their constituents earning less then minimum wage requirements. This was an attempt to scuddle the whole ACA sometimes known as "Obama Care".

When having a conversation with people about insurance, many would use the words "Obama Care" to refer to their insurer. I tried not to smirk. I patiently explained there was no insurance company called "Obama Care". That was a bill passed to force the insurance companies to compete for the business of the uninsured. The bill instructed the insurance companies they could NOT refuse anyone based on a pre existing condition, they could not cancel a customer based on that customer passing a ceiling on health care. The insurance companies could no longer sell junk insurance policies. Some of the policies being sold prior to ACA (Obama Care bill) did not cover pre natal care, and drugs; had no ceiling on out of pocket expenses causing many insured to go bankrupt even with these policies. The insurance companies would also cancel a policy if a buyer got sick thereby reducing the fees they had to pay for that person's care. By doing this they could offer the remainder of their clients insurance at a cheaper rate. Works out great unless you are the one that got seriously ill. You were then suddenly NOT covered. 
Folks only found out after being admitted for open heart surgery or cancer treatment, these junk insurance policies only paid a small amount. They had no idea and assumed they were covered for these major illness. Bankruptcy ensued.

When the cry went up and people reminded the President of the promise that they could keep their prior insurance, he relented. Those polices had to adhere  to the mandates of the ACA and rates increased to the consumer who blamed this on Obama Care/ACA. Check your policy. Make sure you have catastrophic coverage. Make sure your insurance doesn't have a "cap" on coverage. Check to see if the limit of payment on health care for a cancer diagnosis is more then 50,000.00. That amount won't pay for the first week of cancer care. Read the fine print.

Having said all of this, I now have a problem. Recently an acquaintance kept complaining of her "Obama Care' insurance not being accepted by her doctor. I patiently explained there was no "Obama Care" policy. What I wasn't realizing was this is what her doctor was calling it. What he meant was he was not accepting any insurance policy sold through The Market Place. Frankly, I did not believe her. I truly thought she didn't know what she was talking about. My research began.
I was appalled at what I discovered.
She had told me that her doctor said "Obama Care is for poor people." Buy yourself a policy on the private market." Translation? He was not going to get the compensation and reimbursement  from that policy as he would from a private insurance. The "Obama Care" he insisted on calling it pays a bit above the pay rate of Medicare. Saying he wouldn't take her "Obama Care" insurance was his political way of expressing his dislike of the ACA.  Her insurance carrier was Coventry, not Obama Care but it was bought through the Market Place. He said he had never agreed to see "Obama Care Insurance Co." patients (meaning he didn't sign an agreement with Coventry Insurance Company since there is no such thing as an Obama Care Insurance Company.
Again I was stunned at his instructions to her and still was not going to believe her until I did a little research.
I did. I did some research and I'm not done yet on collecting information on this. In retrospect, after researching, this doctor was not in favor of the bill. It was a political response on his part. He could just as well have told her he had taken his limit of Medicare/ACA patients at this " time."
What I have discovered so far is I didn't know much about what was going on with the ACA's effect on the insurance companies.
The reason doctors are not taking patients with insurance bought through the Market Place is..their reimbursement is only a little more then  what Medicare pays them!  Most doctors limit the amount of Medicare patients they take every week/or year as the reimbursement is a mear pittance of what a private policy pays. In order to see a large amount of Medicare patients, they have to up their scheduling of patients in order to recoup the difference in insurance reinbursements and that's why you see your doctor for a quick 15 minute visit and then you are out and the next patient enters the exam room. It's not because the doctor doesn't care about the patient but that he does care about his income.

*to be continued.  I will be talking with medical people on Monday. I want to know if they are turning away people here that bought their insurance from carriers that service this part of the state through the Market.
In searching for information in the ACA bill to determine if it specifically says the reimbursement to doctors will be sliced I found this article.

I have now spent more hours researching the refusal of doctors in seeing the patients who bought their insurance from carriers offering it from The Market Place. Basically, what it amounts to is what has always been going on. Doctors only accept a certain amount of Medicare patients in one period either weekly/monthly or yearly. The buyers of Market Place Insurance are riding along in that same boat. Doctors are only going to accept a certain number of patients paying lower rates at any given time. You might have to shop around as do Medicare patients. Most doctors DO take Medicare patients but they set a limit on how many. One internist here will take one new Medicare patient a week.

Doctors who are saying they never signed up to be a provider for The Market Place consumers are unaware of the three tiers of an insurance company. There is the private insurance policies, the Medicare insurance policies and the Market Place policies. When that physician signed up to be on the physician's list of the private insurance policies he/she was automatically accepting the Medicare patients too and then along come the ACA/Market Place patients who were given the same participating physicians list.
When the ACA/Market Place patient contacts one of the physicians on this list, they are told "NO, I didn't sign up to be on that list" and there the confusion lies with the policy holder and the doctors. The doctors didn't realize they would automatically be listed because they were on the private and Medicare vendor list.

Legally you can force a physician to honor his arrangement, though unknowingly but who wants to see a physician you have taken to court?

I feel that the doctor that saw the person I referred to earlier was taking his shot at bashing the ACA. He could have done better explaining to her his objection, which I'm sure was based on monetary considerations. Since this event, Coventry Insurance Company is no longer covering the state of Florida.

One more event: A friend signed up with United Health Care under the ACA. United Health Care is recommended by AARP. Their Medicare Insurance polices are stellar. Their private and ACA policies are so difficult for physicians to work with that many doctors will not accept them and the ones that do have hours and days of work getting people to answer the phone and deal with pre approvals. I fear Coventry was much the same sort of headache for the doctors.
A perfect storm brewed when the acquaintance referred to earlier contacted a doctor that was biased and an insurance company that was incompetent.

None of this blog addresses the shortage of physicians in the future, the cost of hiring outside source to keep up with billing, the extra staff required to get pre authorizations on the tests ordered by the physician.

A single payer system would have alleviated much of the problems encountered by patient and physician. It has been lobbied against  by the physicians and insurance companies. Their income would have been greatly affected but how does a doctor justify 340.00 for a 15 minute visit? A single payer system would have put an end to these outrageous charges.

Better minds then mine have been addressing the health care issues of this nation. I'm just an observer trying to sort it out.

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