I am a local physician who has lived through some of the scenarios you describe in your article about Anthem Blue Cross and the roll out of Covered California ("Bait and Switch," June 12), and it has been a nightmare.
About half our patients have various types of insurance, so our office accepts nine different types of insurance, adheres to nine different contracts, and has nine different fee schedules. (Very confusing!) Three full time employees keep track of all this, and beg, bicker and bargain with various insurance companies to make sure we get paid. It seems that any reason is good enough to underpay us or deny payment. If we don't catch the mistakes, we lose out, so we pay our staff members their hourly wage as they hold for insurance companies trying to address problems. Sometimes we call the California Medical Association to get help, and sometimes we yell at our insurance broker. We don't bother calling the Department of Insurance or the Department of Managed Health Care because they are understaffed and overburdened. When you need to hire additional employees just to make sure you get paid for your work, the system is broken.
Our office was also offered a significant pay cut to see Blue Cross' Covered California patients, so we declined the contract. However, Blue Cross Covered California patients came in with deceptive insurance cards that looked identical to those of our contracted patients. We were also falsely promoted as contracted providers on their website. Our office and our patients did not find out who had Covered California Blue Cross and who had regular Blue Cross until bills were denied, and it fell upon my staff to inform patients that their insurance had not covered their costs and that they owed us the money. Dumbfounded and dismayed, families wept and raged at our medical billers.
One of our employees resigned, partly because she felt she could not continue in a job that was so hurtful to young families. After sending out patient after patient in tears, she decided the bad karma invoked by performing the duties required by the position could not be justified, and moved on to a happier job. When things reach a point where your employees feel like they will face eternal damnation just for doing their job, then the system is broken.
Every time the company refuses to pay for a procedure, consultation or a medication, the company gets to keep the money! Every time the company suckers some poor clinic into accepting low rates, the company gets to keep the money. Every time the company "forgets" to pay a claim, the company gets to keep the money! Each time the company raises premiums, the company gets to keep the money! The worse the company behaves, the more money it gets. Are we crazy to tolerate such a system?
The Affordable Care Act, despite the best of intentions, has fortified a monster. By mandating that everyone purchase insurance, the industry is stronger and feels emboldened to take even more advantage of patients and healthcare providers. Exponentially larger and more powerful than the agencies assigned to oversee it, the industry finds ways to circumvent and resist restrictions. This leech has gotten firmly latched on to the lifeblood of American medicine and is sucking money and energy out of medical care from all angles. How long are we going to stand for this?
Emily Dalton is a pediatrician at Eureka Pediatrics. She lives in Eureka.