By Nupur Garg, MD
I hear an ambulance fast approaching. I’ll be able to breathe soon, I think. Minutes later, I arrive at the Emergency Department with an IV drip, oxygen mask, and neck brace in place finally breathing again. Three months later, still wheelchair bound with my arm in a sling, a collection’s bureau agent was explaining to me the intricacies of the Palo Alto 9-1-1 system. “The ambulance you took after your accident was not covered under your insurance, you see. You owe the city $798.” “You realize, I didn’t order that particular ambulance, right?” It didn’t matter – I had to pay up. I was billing manager of a primary care physician’s office for two years and in my experience, we never sent our patients bills unless we really believed they were in fact responsible for payment. I was just getting off the phone with the collection’s bureau agent when my medical school Dean of Student Affairs was passing by. Speaking from her own recent hospitalization experience, she advised, “you have to fight for your insurance to cover what they’re supposed to.”
It would not surprise me if the number of phone calls I made to my insurance company three years ago combined with the ensuing collection’s bureau calls that still come to this day gave me another medical condition… that I would then have to fight for coverage for. I am so paranoid about having to pay out of pocket for care that, two months ago, I called my insurance company to “confirm” that care for my dislocated and fractured ankle would be covered by my plan before I even reached the hospital. Even after taking this step, I still receive bills for the full amount of medical expenses, e.g. the family planning visit with my Gynecologist, the urgent care visit for days of abdominal pain, diarrhea, and dehydration after a camping trip, the dental x-rays before a root canal… the list continues. The real problem is that insurance companies do not get penalized for wrongly rejecting a claim, and we have no way of knowing before we receive care how much we’re going to have to pay. Also, not to implicate mal-intention, but insurance companies have zero incentive to accurately pay for claims. That is, they have an incentive to err on the side of rejecting claims.
When I did medical billing, I would look at all the rejections, determine the reason it was rejected, and re-file the claim several times over before deciding whether it was fair to bill a patient. After a few cycles of doing this, the overall rejection rate of my claims dropped drastically. I learned that many, if not most, healthcare facilities do not do this for their patients. After one rejection, they often redirect the full amount to the patient and leave it unto them to fight their insurance companies. As it turns out, the insured patient is not actually insured, unless they are willing and able to fight for their benefits.
One friend’s story serves as a prime example of a health insurance system gone wrong. He had inflamed knees that were warm, red, tender, and appeared fluid-filled. In addition, he had a fever and felt intense pain on mobilizing his knees or putting any pressure on them. In this situation, the only next rational step would be to seek immediate emergency medical care. However, he refused my pleas for him to go to the emergency department stating from experience that if his knee effusions turned out to be aseptic, his insurance company was likely to reject his claim.
As a physician now, I commit to educate and inform. I empathize with patients who are worried about the costs of their care. I remember that diagnosis codes matter. I know that I cannot be lazy about charting. If someone’s chief complaint was diarrhea but a chest x-ray was ordered, I have to include a diagnosis to explain why. It seems simple, but unless I think about the consequences, it won’t actually happen. This is yet another way I must advocate for my patients. It won’t solve the real problem of misaligned incentives, but I can do my part to mitigate consequences.
Nupur Garg is an Emergency Medicine Resident, Medical Informatics Researcher, and Telemedicine Entrepreneur. She can be reached at: @NupurGargMD. She was also a contestant in the 2013 Costs of Care Essay Contest.