The Mystery of Medical Insurance Coverage

“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.