I bailed out of insurance to better serve my patients, slash costs

Dr. Homero Rivas II runs Chattanooga Spine and Body, a private pay practice in Hixson.

Dr. Homero Rivas II runs Chattanooga Spine and Body, a private pay practice in Hixson.

American medicine is being squeezed into an ever-tighter corner in its voluntary self-incarceration in the modern welfare-warfare state. Doctors are concocting a jail break. One way they are crowbarring their way back to professional liberty is to refuse to take third-party reimbursements either from insurance companies or government cartels such as Medicare or Medicaid.

In Chattanooga this important trend beneficial to you and me is coming into view. Dr. David Redd in North Shore runs QuikSurg, a cash-only walk-in minor surgery clinic that abstains from the insurers’ embrace. Another, Dr. Matthew Hitchcock, plans to open a concierge practice in the St. Elmo section of Chattanooga and serve patients through churches and other intervening entities.

Dr. Homero Rivas II, a physical medicine and rehabilitation specialist, runs Chattanooga Spine and Body, a private pay practice in Hixson. http://www.chattspineandbody.com. The Texas native has been in Chattanooga since 2008. His practice as a physiatrist lets him apply his arts to nerve, muscle and bone damage that affect physical movement. 

Dr. Rivas explains why he fled the world of insurance for the free market and the bright prospect of local economy. —DJT

By Dr. Homero Rivas II

Most people would agree that there is a problem with healthcare in the United States. The government, media and health insurance industry have convinced the public that the biggest issue with healthcare is getting health insurance coverage for the public.

The biggest problem with that idea is that health insurance companies do not actually provide healthcare to patients. More to the point, insurance companies do not treat patients, period. Patients receive healthcare when they are evaluated, diagnosed and are treated by physicians and other providers, not by getting or having insurance.

That being said, the real issue with healthcare is getting patients access to physicians and other providers so that they can get treated and receive the healthcare they need. Under the current healthcare system, patients are on one side, physicians and providers are on the other, and the health insurance industry has strategically placed itself between the two.

Many people get health insurance thinking they can then get all the healthcare they want, see any doctor they want, and that they no longer have to worry about paying for it all. Many are shocked to find out that this is not the case.

Clamping down on patient choices

Many get health insurance, only to find out that they may not be able to see the provider of their choice. Insurance companies force patients to see only providers that take their particular insurance by making it cost prohibitive to see any physician who does not take their insurance.These providers are considered “out of network.”

By creating “networks,” health insurance companies control and manipulate patients’ access to physicians and providers, and in turn, access to healthcare. In addition, because most insurance plans have deductibles, most people will still be paying for large amounts of their healthcare out of their own pocket before the insurance begins to cover those costs.

On the other side of medicine, health insurance companies also influence the medical decisions of physicians and providers by determining what healthcare services are actually covered, thus manipulating and limiting treatments that can be offered to patients.

Doctoring — a profession in crisis

I don’t know any physicians or providers that are not frustrated with the current state of healthcare. Polls show that physician job satisfaction has been dropping over the years, with more than half of physicians not satisfied with their jobs as physicians.

I hear of physicians retiring early and/or telling their children not to go into medicine as a career. The main frustration is paperwork and bureaucracy, which have spiraled out of control. Most physicians spend as much time documenting in a patient’s medical chart and filling out paperwork as they do seeing each patient. Medical information that is actually important to patient care is only a small part of what must be documented in medicine today.

Most of what gets put into a medical chart is put there to satisfy government and insurance requirements as well as for medical/legal reasons. If a medical chart is not appropriately documented, insurance companies will deny payment.

The government has medical documentation guidelines for healthcare data collection and fraud detection. In today’s litigious society, many things get documented in a medical chart because of legal concerns, not out of medical necessity. If physicians and providers were not dealing with Medicare and Medicaid or private health insurance, medical documentation would be much simpler, and providing healthcare would be more efficient.

The ICD-9 stalks the land

All documentation in medicine for billing purposes relies on two main components, ICD-9 diagnosis codes and CPT service codes. The diagnosis code is a number that represents the medical diagnosis.

The CPT service code is a number that represents what services were rendered at a medical facility, whether it is an office visit, an injection, medication, procedure, lab, diagnostic study, etc. They may consult a handful of physicians, but the ICD-9 and CPT codes are mainly created in Washington by bureaucrats.

The intent is to have numeric data that the government and insurance companies can collect, organize, and analyze to generate healthcare statistics. There are thousands of CPT codes and ICD-9 diagnoses codes, none of which are taught in medical school. Many of the diagnoses associated with the ICD-9 numeric codes won’t be found in any medical textbooks. Physicians and medical providers generally have to learn them on the job.

Complicating matters further, the insurance companies will typically decide which ICD-9 code will justify paying for a specific CPT code. Many times, more than one ICD-9 diagnosis code will be medically appropriate for a patient, but only one of the diagnosis codes will result in payment. The doctor is forced to make a guess.

Ballooning backroom admin staff

Medical practices have dedicated employees that do nothing but ICD-9 and CPT coding for the sake of billing the insurance companies. Their job is to determine the most appropriate ICD-9 code, assign the diagnosis code to the CPT service code, submit that information on insurance billing forms, and hope the physician will be paid. There is an entire industry dedicated to training and certifying individuals to do nothing more than dealing with ICD-9 and CPT codes for medical offices.

As if that weren’t bad enough, the government is getting ready to switch to a whole new diagnosis coding system in the next few years, which will be called the ICD-10 coding system. Over the years, the health insurance companies have slowly gained more and more control over healthcare.

There was a time when a physician’s decision dictated medical treatment and it was rarely second guessed. In today’s healthcare system, physicians or providers rarely do anything without first getting approval from the health insurance companies.

Insurers piously claim they do not diagnose or make medical decisions — that’s for physicians. But they largely make their own decisions on medical treatments they’ll reimburse. How do the health insurance companies determine which treatments are appropriate? Depends on the insurance company. Ideally, they are using the latest medical research as well as medical guidelines and recommendations from government agencies and established medical organizations.

But don’t doctors already do that? The easy access to medical information via Internet is a double edged sword in medicine. Mountains of good material is on the Internet, and bad. Health insurance companies pick and choose the research and medical opinions to justify reimbursements.

Doctors’ diagnoses become suspect

Another pretended control is through national guidelines and recommendations from medical societies.

Insurers treat medical guidelines and recommendations as absolutes and become critical of and are hesitant to pay a provider who dares to deviate from these accepted treatment protocols. Even the best treatment protocols may only work 75 percent of the time, meaning that one in four patients will likely not respond to the general standard treatment.

For those who don’t respond to the usual treatment, physicians should be allowed to use their knowledge and experience to try alternative treatments without being second-guessed by insurance companies.

In fact, physicians have gone through years of medical training to learn how to analyze medical problems and come up with the best course of medical treatments for their patients for just these types of situations.

Selective research and the absolutizing of medical guidelines create many problems for providers and patients. There was a time when a letter from a physician would be sufficient to reverse a denial by a health insurance company. Now, once an insurance company has an established treatment protocol, it is very difficult, if not impossible, to deviate and still expect to be reimbursed.

The financial reality is that physicians cannot afford to choose what they feel are the best treatments for their patients when an insurance company will not pay for them. By deciding on that or which they pay, insurance companies influence medical decisions more than the public realizes. It’s a dirty secret. With payment controls, insurers veto and override your doctor’s medical decisions.

A profession sells its soul

Many of these problems with healthcare begin when a physician first decides to accept a particular insurance. A physician surrenders much of his/her medical authority to an insurance company and will not have the final word on how to treat patients once the contract is signed. The first insult is the credentialing process to become approved as an “in network” provider. It takes months.

The process involves excessive quantities of paperwork, and in the end gives the insurer authority to review your physician’s medical records and use independent medical reviewers to decide if they agree with your medical treatment plans. This raises an important question.

What is the point of spending that much time and effort to get credentialed with an insurance company to allow its staff to look over your shoulder and second-guess your medical decisions?

Blank checks

A physician “in network” agrees to accept the dollar amounts from a medical service fee schedule that has been determined, almost exclusively, by the insurance company. It does not make any difference what a physician charges. The amount he gets paid is determined, according to the fee schedule that is in the signed contract. To make it even more complicated, every health insurance company has its own fee schedule for every CPT service code. Physicians, however, are obligated to charge the same amount on their bill, regardless of which insurance or whether or not a patient has insurance. This means that a physician knows how much is charged on any given bill, but the actual amount paid by each insurance company will be a different, according to the company’s fee schedule.

The time and legal fees needed to negotiate a reasonable fee for any of thousands of CPT codes and to do it with every single insurance company are beyond the reach of small medical practices. In short, a small medical practice does not have the time or resources and is in no way able to fairly negotiate with a large health insurance company on an equal basis to determine these reimbursement rates.

The insurance companies are well aware of this short-handedness. Most medical practices feel overwhelmed and pressured to accept and sign contracts with health insurance companies without negotiating reimbursement fees. It is in this way that small shops are bullied into signing contracts stacked against them.

In bowels of contracts, shifting numbers

Even worse, health insurance companies have been known slash reimbursement fees after the contracts have been signed. Provider contract with health insurance companies are generally renewed every year.

This means that the reimbursement fee schedule for that year, legally at least, should not change until the following year. But insurers lower reimbursements mere months along.

Several state legislatures have considered barring the practice after lawsuits were filed. Because some insurance companies pay less than others, medical offices generally overcharge for services to compensate for those insurance companies that pay less. The cheapest insurers happen to be Medicare and Medicaid. Their low reimbursements prompts most medical practices to artificially inflate their rates to cover the shortfall.

Financial pressure on doctors’ practices

In insurance lockdown, small medical practices face an existential threat. Hospitals and medical management corporations are big enough to negotiate. In the distress of small players, hospitals and medical management companies take advantage of the distressed market, buying out medical practices and promising to deal with insurance companies so physicians don’t have to.

Doctors’ wages plunge as they become employees. Patient care usually ends up taking a back seat to the larger policies and financial goals of the managing institution. Even if an independent medical practice is not inclined to sell out to a larger business entity, dealing with the insurance companies is getting more and more difficult.

Forty years ago, when a physician decided how to treat a patient, that treatment got done and the insurance companies generally paid without questioning the work. No more.

Illegal practice of medicine?

Deciding not to pay for a medical treatment, in reality, is making a medical decision to not treat. The insurance companies may not have the ability to decide how to treat patients, but they actually do have the ability to decide not to treat patients.

Simple logic would suggest that health insurance companies are indeed making medical decisions. Even if it cannot be proven legally, common sense would say that the insurance companies are indeed practicing medicine without a license. Make no mistake, the insurance companies are in business to make money.

They collect as much as possible in premiums and spend as little as possible on patients, paying providers as little as they can. As unpleasant as that might be to admit, that is the strict and simple business reality of health insurance companies.

Being eaten alive

Barriers to compensation are high. Denials, complicated appeal processes, high premiums, high deductibles, rigid or limited networks, and multiple, complicated, healthcare plans serve to maximize profits.

One nasty tactic is the random denial that requires a letter of medical necessity.

Others are peer-to-peer reviews, prior authorizations and excessive appeal paperwork. All these tactics consume a physician’s time, office staff, and resources. Medical cost inflation brings trouble for people who have to pay for their own healthcare.

Chaotic standards

Making problems worse: Insurance companies do not inform physicians or providers what criteria they are actually using.

Typically, when a provider calls the insurance companies to clarify what needs to be documented in the patient’s chart in order to get something approved, the provider will be told that they cannot give that information because they (the insurance companies) are not allowed to diagnose the patients.

This leaves the provider guessing what needs to be documented in the patient’s chart in order to convince the insurance company they should pay for a given medical service. A provider is not only documenting what they feel is medically necessary to put in the chart, but they are also documenting what the insurance company and, in the case of Medicare and Medicaid, the government, wants.

Once these criteria are figured out, a physician has to become a part-time lawyer to make sure those criteria are documented and worded correctly just to satisfy the insurance company or government. This often forces physicians to change how they conduct their patient evaluations, knowing that certain exam or lab findings must be documented before it will be paid for by insurance.

Making this worse, insurance companies often make changes to their criteria for payment without notifying anyone. Most offices are busy seeing patients and usually don’t have the time and resources to complete the required paperwork or spend the time waiting on the phone in order to talk to an insurance company representative. The insurance companies are well aware of this and likely make the process time consuming for just that reason. If only a portion of denials get appealed, then the insurance company has succeeded in saving themselves more money by not paying for the requested treatments that did not get properly appealed.

Remembering why we’re doctors

With the government and media so focused on health insurance, they’ve lost sight of what healthcare is really about. The key to healthcare is to make physicians and providers available to patients so they can see the physicians of their choice and receive the medical treatment they desire — and deserve. Control of healthcare should be in the hands of patients and providers so that they can make medical decisions on their own terms. There was a time when the doctor/patient relationship meant much. It was respected.

The goal in medicine should be to restore that relationship and level of respect. It is important to remember that patients do not receive healthcare when they get insurance. Patients receive healthcare when they can see the medical practice of their choice and receive the treatment desired by both. When a patient and provider decide on a medical treatment, they should be able to follow through with it with minimal interference from insurance companies or the government.

After all, physicians have gone through years of medical school, residency, and fellowship training to learn how to diagnose and treat patients.

Insurance companies, healthcare management outfits and government haven’t.

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