July 3, 2022
  • July 3, 2022

Medicare, not health care, needs reform – Lowell Sun

By on February 11, 2022 0

A family member fell seriously ill last year. After some initial tests, a malignant tumor was diagnosed. Surgery was scheduled, followed by chemotherapy. Everything went as planned, without any medical problems. My family member and I are both well educated, with a background in medicine, health economics and risk analysis, which should have prepared us to maneuver the demands of our health insurance provider and ensuring that copays and pre-clearances were processed as necessary.

We were seriously mistaken.

We chose the providers, the surgeon and the establishment so that they are all networked. The problem is that some of these facilities use radiologists, pathologists and anesthesiologists who choose to be off-grid.

Why is this done? These specialists receive higher compensation when they are out of network than when they go into network, where reimbursement rates are lower. This means that patients are then responsible for all charges for these services, even if they have no choice of these providers.

In Illinois, a law protects patients from such circumstances. Insurance policies must have what is called a facility-based provider benefit, which means that if a patient is cared for in an in-network hospital and out-of-network radiologists, pathologists or anesthesiologists provide services, these services are considered network services. , and mostly billed at supplier-designated rates.

Even with the facility provider benefit, insurance companies can add rules and limitations to this coverage that they don’t communicate. For example, they can require that the pathology be invoiced on the same date as the acts in the network. So if a pathologist bills for work one day after care is provided at a network facility, the insurance company may deny the charge, forcing the pathologist to bill you directly.

Another example occurs when a pathologist must use a specified number of units for tissue analysis, while the insurance company imposes an arbitrary limit on the number of units that can be billed per day. If this limit is exceeded, the insurance company declines all charges rather than paying up to their arbitrary limit.

The other problem with these unwritten rules is that the patient is responsible for understanding them and communicating them to physician billing offices. Otherwise, billing offices assume the charge is denied, without determining the reason, and bill the patient directly.

Effective in 2022, the No Surprise Act provides comprehensive protection against such nationwide billing practices, providing patients with financial protections that go beyond facility-based provider benefits.

The lessons learned from the illness of a member of my family are that there is a triumvirate of players who are out of sync with each other.

First, there are the medical providers in the network who provide care and want to be paid for their services.

Second, there are insurance companies that have an interest in providing minimum payments for services and keeping a veil of uncertainty around their rules and policies.

Finally, there are the patients who work to stay in the network, but find themselves indebted for legitimate costs covered by their health insurance policy, but who require finesse and communication to facilitate their payment.

What is the solution?

A system that creates a homogeneous network of service providers covered by all insurance companies. Without such a simple set of transparent rules for insurance companies and providers, patients will continue to fall through the cracks, with uncovered medical expenses falling on them.

Whether it’s a single-payer system or multiple-payers following a uniform set of rules, changes are needed.

The illness of a family member opened our eyes to the state of health care in our country. Patients and doctors deserve to be respected and treated fairly by the health insurance industry, so that patients can receive the medical care they need and doctors can remain accountable for the medical care they provide.

Sheldon H. Jacobson is a professor of computer science at the University of Illinois at Urbana-Champaign. This column was written for the Chicago Tribune. Go to chicagotribune.com. Distributed by content agency Tribune.