by Dr. Pete Barnes. D.C.
May 2009, VIEW Issue 14, Pg 10: Many of you have medical insurance, that you pay a monthly premium which usually costs just short of a king’s ransom. Many of these premiums are two or three hundred dollars for just one person.
When it’s time to go to the doctor’s office, you hope to recoup some of those steep payments by paying just a small portion of the charges (co-pay) or feel that the insurance should pick up the whole tab. All of a sudden you’re told that your deductible hasn’t been met and now you’re paying out of pocket for the services you seek. Frustrating at the very least, but to keep those premiums down, you opt for a high deductible. Some of these policies have such high deductibles that the only way you’re going to meet them is if you are suffering with a serious disease requiring extensive treatment and/or are hospitalized.
Let’s say you’re one of those “lucky” ones that work for a generous company that provides magnificent coverage that has no deductible or a very small one so that the first visit takes care of it. Now you’re in a position to use that coveted plan. Now this is where the fun begins! Your doctor checks on benefits, those benefits are verbally confirmed and the billing is submitted to the insurance company for payment. Three, four, maybe even six weeks pass and all of a sudden your doctor gets a letter challenging those charges or partially paying the charges and remitting what they (the insurance co.) feels they should charge for those services. This is what they call “Usual & Customary.” Or maybe that letter is requesting additional documentation of that visit before they even consider reimbursement.
These practices are common-place with insurance companies. They love to delay and many times deny paying what the policyholder (YOU) have paid for in coverage. These business practices are making more and more doctors apprehensive about accepting any type of insurance. Many doctors, with their practices being small businesses, cannot afford to wait and hope for payment, payments discounted, or continual business as usual denials for services rendered.
When it comes to personal injury cases it really gets interesting. Recently I had a patient, let’s call her Alice, who had been involved in a rear-end automobile accident. The person that was at fault had Farmer’s Insurance. Alice came in with all the proper information including a letter from the Farmers Insurance Adjuster including the claim number.
My office proceeded to contact Farmers to verify responsibility for payment and where invoices should be sent. The adjuster told us that payment would be made only after treatment was completed. When Alice was finished being treated, we contacted the adjuster only to be told that payment would be made to the patient and that it was the patient’s responsibility to pay us.
Staying in close contact with Alice, she called us a few weeks later upset and in tears. She told us that Farmers only offered to pay her $1800 for the accident. That wasn’t enough to even cover her medical expenses not to mention the pain, suffering, and inconvenience. She didn’t know what to do. She didn’t have the money to pay the difference and even if she did, was that fair for her to be penalized for being a victim of an auto accident not her fault?
When situations like that occur, which is quite often, an attorney must get involved to settle the matter. Unfortunately many months or even years will pass until the case is set to go to trial. Miraculously, right before the case goes to court, the insurance company settles out of court. What this has done is to delay payment so the billions that they sit on continues to grow with interest when a small portion of that interest would actually pay the claims, and the attorneys wind up making the money. Sad but true! Situations like this are happening every day.
Supposedly there is a governing body that oversees these insurance companies called the California Department of Insurance with an Insurance Commissioner (www.insurance.ca.gov/contact-us/0200-file-complaint).
Well good luck getting anything done. These insurance companies are so FAT (wealthy) that they can sit on these claims and get FATTER and FATTER!
And the beat goes on.
- Dr. Pete Barnes, D.C., Ventura
This Article: http://bit.ly/2iuUqD8
Article Source: Dec. 2009 • VIEW Issue 14, Page 10
Related Story: 2009: Obamacare? Retrospective in Higher Costs
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