The “Health Insurance Card” and Health Insurance have taken on an importance in everyday life. These two items have, in a way, taken on a life of their own. Amidst today’s fervent, raging and emotionally charged debate over health care reform, the whole concept of Health Care Insurance should be re-evaluated. This is just one Health Care practitioner’s perspective on one small aspect of health care delivery. It is fueled out of my confusion that patients don’t seem to understand their personal responsibility for payment of the services (care) that they receive (purchase). It is almost as though health care has been devalued to the point that we don’t comprehend paying for it. www.healthozz.com
There is much confusion regarding the role and use of health insurance. Health care coverage is a product. It is sold to you, the consumer, by businesses. The business’ product is “health care coverage.” Coverage varies depending on the plan that you purchase. Cost of the “plan” varies depending on the scope of the coverage. Just like the size, quality and performance of an automobile may vary depending on the price you are willing to pay. The more you pay, the more you get. Health care insurance coverage works the same way.
Companies providing health care insurance are profit making businesses. They are not charities. I am hearing a great deal of mumbling (ok it’s more like shouting) about the profits that these companies are making. Many of us own stock in these companies in the form of our mutual funds. They are supposed to be profitable. Why are we thinking that there are moral dilemmas inherent in profiting from helping someone improve their health? Why should saving a life, solving a skin rash problem or counseling someone on being a better parent be non-profitable ventures? Can I be the only one seeing the benefit in all of these? I would pay for these. And if we wouldn’t pay for these services, is it the services themselves or our own selves that we fail to value?
Most people don’t even realize the single largest benefit to being enrolled in a health insurance plan. The largest benefit to health care insurance is that it buys the consumer a discounted rate for any health care related services that it covers. This is the biggest single benefit and most consumers don’t even realize it. When a provider is “participating” with an insurance company they agree to accept a fee lower than their full regular rate. HMO and POS plans pay the lowest fee to providers. PPO plans pay better, but still lower than the provider’s full rate. When a provider is “participating,” they always accept a “negotiated fee schedule” which is lower than their regular rate. The patient is responsible for only a co-payment as long as services provided remain within the benefits of the plan that they purchased. If the desired service is not covered in the insurance plan, the consumer is responsible for payment in full. Referencing back to the automobile analogy, if your care didn’t come with 20 inch rims and you want them, you have to buy them. You don’t expect the car dealer to pay the auto store for your rims.
When a provider chooses to be “non-participating” with an insurance plan, they charge what they want for their service. The “plan” usually covers up to a percentage of a “usual and customary rate,” or UCR. A provider can charge the UCR exactly, or above or below it. The patient (consumer) is responsible for the balance of the unpaid bill. In many instances, the patient pays the provider directly and in reimbursed by the insurance company. HMO and POS plans usually do not cover services provided by non-participating providers. This is partly how the can keep the cost of the insurance to the consumer low. It does, however, limit the consumer as to which providers will be covered for payment.
So with this understanding, health insurance is a product that we convert into a form of “currency” accepted by some providers as partial or full payment for rendering a service. It is the equivalent of dollars, pesos, a check or credit card. It is, in a way, a “promissory note.” It is a promise to the provider that they will be paid several weeks later after sending the insurance company a bill. It covers what the creator (the insurance company) and the service renderer (the provider) agree that it covers. Just as your local grocery store may agree to accept dollars and credit cards but not checks or pesos, your health care provider may or may not agree to accept your insurance as payment for a service.
The dilemma faced by many providers is a patient’s lack of understanding of the scope of coverage, payment and benefits, and the role of the insurance card in all of this. Let’s compare the insurance card to a credit card or a check. Some merchants accept them. Some do not. It’s up to the discretion of the merchant. If the credit card goes through at the time of the billing with no problem, you get your merchandise. If the card is declined, you either provide alternative payment, cash, check or money order, or you leave the store without the merchandise. If your check bounces, you don’t get the product.
Maintenance of the card (or currency) is the responsibility of you, the consumer. If your credit card has run out of date, is over the limit or has insufficient funds, you need to provide alternative currency to leave the store with your merchandise. The same is true with the health care plan ID card. If your currency is invalid, meaning, your plan denies payment, you need to provide alternative currency. And it is your responsibility to maintain your currency (card) as current and active.
One of the most time consuming and costly activities in any doctor’s office is dealing with insurance companies. The following activities by a doctor’s staff cost money beyond what a consumer can imagine. They are: insurance verifications; insurance authorizations; billing; phone calls after denial; re-billing; bookkeeper recording and tracking; co-payment billing; and on, and on, and on.
Patient understanding of the concept of an insurance card as currency can go a long way to a smooth and successful transaction with the provider (the doctor). The health insurance plan covers what it covers. And doesn’t cover what it doesn’t. It is a product that has utility to the extent of the conditions of the purchase. And by purchase I mean the purchase of the insurance coverage. If the insurance doesn’t cover something, the consumer’s complaint is with the insurance company, or more likely with the employer whom negotiated the terms of the insurance coverage on behalf of the consumer. The provider (doctor) is not responsible for the terms of coverage of the insurance policy.
So let’s summarize and make a point. Health insurance is currency. It isn’t a carte blanche to any and all that the doctor may have to offer. It’s a product that you purchased. It allows you access to what you agreed to when you bought it. And most of us didn’t read all of the 2,000 pages (exaggeration) in the purchase agreement at our company “open enrollment” meeting. It is your (the patient’s) responsibility to make sure that the currency is valid and covers the procedure that your are requesting, just as it is your responsibility to be sure that the check will clear or that your credit card has room on it when you make any purchase.
I am concerned at the present use of the word “entitled” when we enter into the health care debate. Health insurance is a product that you purchased. We convert that product into currency to purchase other products, or various forms of health care. As far as what we are “entitled” to, I question if we are entitled to anything. Perhaps we are entitled to opportunity and access. If we see our health and health care as our personal responsibility, and that we may earn these, we may regard them more highly and take better care.