The average healthcare insurance CEO makes millions in bonuses. The average family in RI makes $63,870. Yet insurance companies have multiple roadblocks in place to decrease what they cover for the average patient.
As primary care doctors, whether we practice in our model of direct care at Direct Doctors (monthly membership), or a traditional fee for service model (you pay per visit, usually billed to insurance and then a copay requested from you), all PCPs have to jump through insurance company hoops.
For example, if I see a patient of mine who has injured their knee and it seems pretty certain to me they have torn something that likely requires surgery (and won’t get better with just therapy and ibuprofen), my job as the physician is to recommend and order for an MRI. If a patient does not have insurance, or has a healthshare like Liberty, I can send that order directly to the imaging facility and the patient can pay the cash price, which in our experience is from $400-700.
However, if that patient has insurance, their insurance will require their PCP to do a prior authorization. In a typical practice, this means that some staff member (often remote from the doctor and patient) will complete a form or wait on the phone to chat to a non-clinical employee of a third-party company who will ask a bunch of questions, which will be answered to the best of the staff’s ability, about the visit and info shared between doctor and patient. If this process is done seamlessly, the authorization is provided for the doctor-recommended test. Many offices refuse to do these because it is a process that the office is not getting paid to do.
When this process goes wrong - which happens more often than not - the staff doesn’t answer the question right, the non-clinical third-party employee doesn’t have authority to approve it, or something gets lost in the shuffle - the patient waits. The MRI can’t be done. And the doctor is frustrated. At our practice, we streamline this a bit by having our doctors directly submit their own authorizations - meaning, we spend the time to be sure our perspective is heard and our patient’s testing is approved. Even in our cases, sometimes we are required to do a clinical review - so we have to schedule another call, get on the phone and argue the case for this very straightforward/clinically important test. Even then, this can often be denied.
The reason I’m explaining this whole circuitous process is to highlight how many hoops we all jump through to do a simple thing - get a test “covered” for a patient whose doctor (who graduated from medical school and residency!) knows they need to do. When someone with a high deductible plan finally gets their “approval” for a knee MRI, they are charged the “insurance-rate” which tends to be in the $1000-2000+ range after insurance applies it’s “contractually obligated adjustment” from our experience. If a patient has not met their deductible they owe that whole thing.
When it comes to the price you pay for your insurance, realize where your dollars are going. All of those prior authorization staff are being paid to do their jobs. Those CEOs are profiting from the denial of coverage and the negotiated out of pocket deductibles many patients carry these days. We practice primary care differently and we work with patients with any non-HMO insurance to help navigate this complex system.
Lauren Hedde, DO and Mark Turshen, MD are Family Physicians and Founders of Direct Doctors, Inc. a Direct Primary Care Practice.