Being a provider and medical biller today, is a world of cell phones, faxes, internet, laptops, pocket PCs, e-mails, instant messaging, debit cards, employer sponsored health care, electronic claims, insurance verification, direct deposits, and remittances.  A completely different world from that of just five years ago.  But, doctors, hospitals, medical billers and debt collection agencies are still operating their financial business as if it were the 1950s.

Burger King, McDonalds, Wendys, Taco Bell, Kentucky Fried Chicken, K-Mart, Target, WalMart, Winn Dixie, Publics, Piggly Wiggly, Ames, Macys, Toys R Us, Radio Shack, Gas Stations, Hotels, Banks, on-line travel agencies, flower delivery, your power company, your car insurance company, your cell phone company, Five Star Restaurants to the local take out Chinese restaurant and many other businesses, now operate in the 21st Century.  You can pay with a credit card or debit card with ease.  By the time you get home, what you paid for is already deducted from your bank account.  You can sit in your bed and pay your light bill at 2am.  You can drink a Venti Mocha Delight at your local coffee shop and pay your car insurance via your lap top and WIFI.  What you can't do is pay your medical bills on line, make appointments, and do many other things that could be done if we were as savvy as today's businesses.

Many of us still send claims by paper, even though we could send them electronically.  We're taking baby steps towards the electronic medical record.  Many providers and hospitals do not use what is available to verify benefits, or to check claim status.  How simple would our lives be if we could have the patient log into our practice website, make their own appointments, fill out the required forms, pay their bill on line using a credit/debit card or on-line check, or have their bill e-mailed to them?  Some practices and medical billing companies are already doing this.

Some of our problems lie with the insurance companies themselves.  They have worked hard to put things on line to access such as provider manuals, provider enrollment forms, claims submission, claims status checking, and more. Some insurance companies are starting to let doctors know, at the time of service, how much the patient owes the doctor.   But the problem that we have is that many of their patients go out of network to non-contracted providers and the insurance company does not want the non-contracted provider to access their on-line information.  The intent of the insurance company is to get the doctor to be contracted in order to have access to this information.  But the provider may not want to be contracted due to problems the doctor had with the insurance company when the doctor was contracted, such as not paying claims on time or paying the claims at an amount that is less than the contracted amount. 

If the patient seeks care out of network, then the patient is establishing a relationship with that provider.  Once that relationship is established, then the non-contracted provider should be allowed access to the patient's insurance information to verify benefits, submit claims, check the status of the claim, and to be paid for his/her services. 

Just as the businesses of today have established a network of providing goods and services in exchange for electronic payment, the medical and insurance community should band together to do the same.  I understand the concerns over privacy issues but why aren't we concerned when we go into a Duncan Donuts for a coffee and we take out our bank card and swipe it?  We can live in Alaska and travel to Massachusetts and go into the Bull and Finch Pub and scan our debit card and our drinks are paid for immediately from our bank in Alaska.  The scanning machine didn't decline the payment because the bank wasn't an Alaskan Bank.   We must do the same with our patients. When the patient comes to us for medical care, they present their medical card.  They swipe their card and on the screen at the reception desk is their health insurance information from ABC Insurance.  In addition, their health insurance information from XYZ insurance shows up.  ABC Insurance tells the provider that it is primary.  The health insurance computer gives authorization and the patient can now be seen.  When the doctor is done, the visit information is sent to the insurance company and the insurance company tells the doctor how much the patient owes.  The insurance payment is automatically deposited into the doctor's bank account.  The patient scans their debit card and they pay their portion of the visit.  If the claim is denied, then you can perform an appeal on-line.  ABC insurance sends XYZ insurance the claim info and XYZ insurance pays its portion.  Can this happen?  Yes it can.  Even with Medicaid and Medicare.

In my personal opinion, this won't happen because many of the health insurance companies have gotten too big and as a result, I feel that they have adopted a "god-like" complex.  "YOU WILL CONTRACT WITH ME AND DO AS I SAY OR ELSE!" If the doctor doesn't want to be contracted, the insurance company goes to the hospital and puts pressure on the hospital.  They tell the hospital, if a doctor is non-contracted with us, we will pay you less on your claims and we will tell our members not to use your hospital.  I know this because I had at least two health insurance representatives tell me this, each from a large insurance company.  I have seen the hospital remove a doctor's privileges because the doctor refused to contract with these insurance companies.  To me, this could be something you would see Vito Corleone do in "The Godfather".  So, as they said in the book and movie, "Either his brains or his signature would be on the contract."  Well, instead of the doctor's brains, his livelihood and his privileges are on the line.  One insurance company says, "Doctor, you contract with us or we will send the payment to our members instead of you and we don't care if you have an Assignment of Benefit form." Another insurance company says, "So what if you have claims that are unpaid or paid incorrectly, we don't resolve claims issues for non-contracted providers and NO! You can't have access to our website to verify if the patient has benefits with us."  Is this the way to do business?  Why force a doctor to be contracted with you???  Take a look at the lawsuits that are taking place.  Look at how they respond to our claims with the frivolous denials such as timely filing, inclusive denials with no foundation, and medically necessity denials.  Look at what is happening with your own insurance.  Your premiums are increasing every year, your out of pocket expenses are increasing and the amounts the insurance company pays is decreasing.  This doesn't count how low they want to pay the provider.  Why???  One word:  "Profit"  To all the health insurance Presidents, CEOs, and Board Members:  "You are spending more money by fighting then you would by cooperating.  When you deny, we appeal and the appeal costs you money.  Each lawsuit costs you tons of money in legal expenses.  Is it better to pay a $100 claim or is it better to spend $3,000,000 in attorneys fees and court costs fighting the $100 claim? Why deny the non-contracted provider access to the patient's information if the patient wants to see that doctor?
You gave the patient permission to see the non-contracted doctor. 

The health insurance industry could make a profit if they stopped their method of doing business the way they are.  They could reduce their legal costs by paying the claims at a decent amount and stopping the frivolous denials.  They could reduce their administrative costs by paying the benefit which would reduce appeals.  They could treat non-contracted doctors with a friendly and open attitude and allow the non-contracted doctor access to the patient information.  Maybe by being a little more pro-patient and pro-provider, doctors will want to be contracted and will negotiate for a decent reimbursement.  By establishing a health network, where we can all talk to each other, insurance company, hospital, provider and patient, we can make our healthcare something to be proud of instead of being the laughing stock of the world.  We have to get out of the 1950s with the way we all do business.  It's the 21st Century and we have 94 years to go.  If we've come this far in just 5 years, imagine where we will be in 5 more if we all worked together to benefit each other. 

By Steven Verno, CMBSI

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