There is a lot wrong (and right) with health care in the United States, one of the things that is wrong is patient expectations and perceptions.
Consider this real life example (a typical case).
A patient undergoes surgery and during the main procedure, the surgeon performs a secondary procedure, same incision, one use of the operating room, one anesthesia. During this procedure, the surgeon engages the services of an assistant surgeon.
When the claims are processed, only 50% of the second surgical procedure is paid and the assistant surgeon is denied. Why, because a second procedure performed at the same time as and in conjunction with a primary procedure does not warrant a duplicate payment as if there were two separate procedures. Why wasn’t the assistant surgeon paid, because it was not required by the hospital and because there was no indication that it was medically necessary. All health plans, including Medicare apply a medical necessity standard. If they didn’t costs would be more out of control than they are now.
So, what does the patient (employee) do, he blames the insurance company for not paying what the doctor charged. He appeals the claim to a review board and it is again the denied. In this case, the review board is a committee of the employer because this is a large self-insured plan and the “insurance company” is acting only as an administrator and has no financial stake in the payment of claims.
Nevertheless, the insurance company is the bad guy. When the employer panel upon appeal hears the claim, an independent third party reviews the entire medical record and agrees that there is no medical necessity for the assistant surgeon and that the second procedure is merely a form of unbundling the billing.
Oh, did I mention that neither the surgeon nor the assistant surgeon participates in any health benefit plan, often a good indication of a high fee or the practices that caused the denial of this claim.
The patient is on the hook for $6,000 and of course, he blames the insurance company and now the employer.
But what is missing, well at no time did the patient question the billing practice of the doctor, at no time was there any thought of going back to the doctor and saying what gives here, why are you charging these fees, why was an assistant surgeon necessary when no one else thinks so?
Now you know one of the fundamental problems with the health care system in the US is the failure of patients to accept responsibility or to hold health care providers accountable for their practices. The doctor is always right and the insurance company wrong.
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