“Does my insurance cover this?”
I cannot calculate how often a patient poses this inquiry to
me assuming wrongly that I have expertise in the insurance and reimbursement
aspects of medicine. If I – a
gastroenterologist – do not even know how much a colonoscopy costs, it is
unlikely that I can speak with authority to a patient’s general insurance
coverage issues.
Of course, patients assume that we physicians have an
expansive expertise of the medical universe, both in the business and the
practice of medicine. Often, friends and
acquaintances will informally present a medical issue for my consideration that
is wildly beyond my limited specialty knowledge, and yet they expect an informed
opinion. “Hey, aren’t you a
doctor?” Yes I am, but if you think a
gastroenterologist – a Colonoscopy crusader – can advise you on your upcoming
hip surgery, psoriasis treatment retinal detachment, or cardiac rehab, think
again.
And, I likely know more about psoriasis treatment than I do about
the enigma of insurance coverage. I have
to check with our billing expert to understand my own medical coverage and I’m
in the business. And, at the risk of
appearing as a simpleton to my erudite readers, I cannot aver that I fully
grasp the meaning of the E.O B. (Explanation of Benefits) forms that I receive
for my own care that purport to explain exactly where my insurance company
responsibilities end and mine begin.
Imagine for a moment that you are an actual physician as you
counsel a patient who is sent to you for a screening colonoscopy. (To assist you in this role play, a screening
colonoscopy means there are no symptoms or any other abnormalities that would
justify the procedure. A screening study
is done on patients who are entirely well as a preventive medicine
exercise. In contrast, if a patient has
a symptom, such as pain or bleeding, then the colonoscopy is considered
diagnostic and not screening.) You advise your 50-year-old patient that his
screening colonoscopy will be fully covered by insurance. The patient is
happy. However, during the screening
colonoscopy, a polyp is discovered and removed.
Indeed, removing polyps is the mission of the procedure. However, polyp removal automatically changes
the procedure from screening to diagnostic.
And, guess what? Now, the
procedure may not be free and the patient may be subject to copays or diving
into his deductible. When the patient
receives his E.O.B, and properly decodes it, he is no longer happy. Then, our office is likely to receive a phone call.
Can Sherlock Holmes Deduce the Cost of Colonoscopy?
This is but one example of the Medical Insurance Industrial
Complex. Even our most seasoned patients
are no match against this machine. It’s not a fair fight. They make the rules, change them at will and
serve as the referees. And, if the
insurance company ruling doesn’t fall your way, relax, you can certainly appeal.
This process is about as pleasurable as undergoing a rigid sigmoidoscopy. The appeals process is not for the faint of heart. You must have the patience of Job, the
fortitude of a Navy SEAL, accept rejection gracefully, welcome irrationality, regard a dropped
phone connection as an amusing event and have several consecutive hours
available typically at times most inconvenient for you. On reflection, perhaps the sigmoidoscopy is
the more pleasant option.
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