This is our process: we call for authorization, get approval for a procedure, and bill the insurance company, but half the time the insurance company then decides not to pay or the patient must pay a larger portion. We often have to appeal or resubmit bills or remain on hold for hours to discuss the authorization with an insurance representative.
In what world would this be acceptable? Can you imagine telling your plumber after your pipes were fixed that you would pay nothing or only 40 percent of the cost? Then you make your plumber wait three months for payment?
We physicians have no automatic explanation of benefits that pops up when patients give us their insurance card. Contracts are confusing, vague, and contradictory. This is so even for my staff of insurance experts.
We do not know if something will be covered sometimes until after the service has been authorized and provided. We bill the insurance company, only to receive a notice: “This is not a covered service.”
This occurs even when the exact service was covered last year with the same insurance company.
I recently delivered a baby. In the sixth month of pregnancy, my office called the patient’s insurance company to ask about coverage for the delivery. She was informed that “the patient’s delivery will be covered at 80 percent of the contracted delivery rate.” We then know the patient will be responsible for 20 percent.