They Profit by NOT Helping You….

A recent New York Times article shed light on some dark truths about the broken health care system in America:

  • Health Insurance Companies profit by NOT helping patients.
  • Health Insurance Companies profit by NOT helping doctors.
  • In the primary care setting, Health Insurance Companies erode the doctor-patient relationship.

With Americans delaying medical care during the COVID19 pandemic, health insurance companies have padded their bottom line. The patients are still paying for their insurance premiums, but the companies do not have to pay for services that are not rendered.

As the article highlights, even with the CARES act mandate to cover costs of COVID related testing, insurance companies don’t adequately reimburse doctors for their services. In this case, not only are they not even reimbursing the cost of the test kit, they are certainly not reimbursing the doctor for their time and expertise in administering and interpreting the test.

 Health insurance companies will make both patients AND doctors jump through frustrating, time-intensive hoops for reimbursement. I have been on both ends of this demoralizing receiving end, as a physician and a healthcare consumer. What is even more devastating is when health insurance companies blame doctors for the low reimbursement or refusing to cover a service for a patient:

“Your doctor wrote the wrong code in the bill.” (I confess, I did not have the all the billing codes that all the different insurance companies required for different conditions.)

“Your doctor did not submit enough information with their claim.” (Translation: This usually means the physician did not click the right boxes in the electronic health record’s template documentation for the coder, not that the physician did not write a thorough note on the patient’s condition.)

“Your doctor prescribed you a non-formulary medication for your diagnosis.” (Translation: This is never related to whether the medication is appropriate for the patient’s condition, but rather what back-handed negotiated deals have occurred between the insurance company and drug companies.)

Comments such as these breed mistrust in the doctor-patient relationship. The patient wonders if the doctor is ignorant, incompetent, or worse, deliberately sabotaging the patient.

One of my principal sources of distress when I worked in the world of corporate medicine was when a patient asked me the cost of a medication, lab, diagnostic test, or specialist service. My answer was always:

“I don’t know.”

Because of the unacceptable utter lack of price transparency in the health care industry, patient’s often end up with surprise bills from their insurance companies, who then have absolutely no problem blaming the physician for the bill.

But think about it: insurance companies do not want you to feel loyal to your doctor. They don’t want you to have a close, long-term, trusting relationship with them. If the doctor ever parts ways with that insurance company, they want you to follow the insurance company, not the doctor.

There is a place for health insurance in healthcare. Insurance is essential for catastrophic events like surgery, emergency department visits, hospitalizations, expensive diagnostic tests, or visits to a specialist. However, in the world of primary care, health insurance companies only function as a middleman that artificially inflates costs and sabotages the doctor’s relationship with the patients they serve.

One of the most liberating aspects of owning a small concierge practice now is that I CAN be completely transparent about prices with my families. There are no surprise bills. Before any families sign up to as members of Culver Peds, we discuss our enrollment and monthly membership fees. When I prescribe a medication, for example, I disclose our prices if the family chooses to pay out of pocket. Families always have the option to use their health insurance for prescribed medications or they can utilize our in-house pharmacy where we offer common pediatric medications at deeply discounted rates with full price transparency.

I also love that once a family joins us, we have the time to work together to find the most cost-effective ways to meet their needs for any outside services, including medications, labs, X-rays, or referrals. And one of my greatest joys is to be able to do any of our in house labs with no additional fees at all including COVID19 rapid antigen, COVID19 antibodies, or Rapid Flu tests for our patients. I extend these services not just to the children, but all of these are for their parents or guardians too. The only test we offer in house that we bill to parents (but we don’t charge the kids) is the COVID antigen test at a discounted rate.  

At Culver Peds, we work for our families. We do not work for insurance companies. We do not work for bureaucrats. We do not work for a large profit-driven system.  

Our goal is to become the best pediatric practice in the state of Indiana. If your child is not yet part of the Culver Pediatrics family, sign up in the email opt-in below to learn more about our boutique pediatric services.  


Burned By Low Reimbursements

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