naturopathydigest.com -- Insurance Coverage: A Double-Edged Sword, Part 2

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Insurance Coverage: A Double-Edged Sword, Part 2

By John Hahn, ND, DPM

Many of us in the health professions have been practicing for a number of years and believed, when we opened our practices, that we were independent practitioners and entrepreneurs fostering excellence in medical care that was governed by the market.

In other words, if you are a good doctor, you will get referrals from satisfied patients and have a large and successful practice.
Today, however, this incentive for excellence has been removed by the fact that all doctors, regardless of their quality of care, are paid the same by insurance carriers for the billed CPT code. And as we all know, not all of our colleagues have the same clinical skills, diagnostic acumen and level of commitment to patient care. These facts were evident when we went through medical school and were able to see the level of performance of our fellow students before they became our colleagues. Attorneys who are good at what they do demand and get higher fees than run-of-the-mill attorneys who do the same sort of legal work. If a physician were to try and model this picture, they would be brought before insurance audit and state licensing boards for holding themselves out to be better than their colleagues.
Today, we are graduating students from medical, naturopathic and osteopathic schools who have a mindset that they would not mind being employees of an insurance company and follow the dictates of company policy, rather than the dictates of good medicine. You might say, "Well, if this is the case, then why aren't there more malpractice cases against doctors who are working in these large HMO groups?" The answer lies in the fact that, at least in Oregon, where I practice, these large groups that employ physicians, such as Kaiser and Legacy Health, do not have to report adverse reactions or adverse events caused by their physicians to the licensing boards. This "Non-Reporting Policy" was just changed this year due to the fact that Dr. Patel, a medical doctor and employee of Kaiser Permanente, killed several patients over a period of time due to poor medical techniques. This story made the local and national news, and the families of the deceased patients wondered why this person was still practicing and being paid by this HMO. After the media aired this story, pressure was placed on the state licensing boards and the HMOs to change their policy of disclosure of physicians with bad clinical results.
During the early 1960s, when Medicare became a law, the dental profession was excluded from coverage by this new law, with only medical doctors, osteopathic physicians and podiatrists being included. The original Medicare law basically was implemented to help retired individuals pay for the 20 percent co-pay not covered by their private indemnity insurance carriers. But as we know, over time, Medicare has become a political football: It is now an entitlement and a primary source of insurance for a large number of Americans. This number also will increase as the number of retired baby boomers increases. There were approximately 78 million Americans born between 1946 and 1964, and they account for more than one-quarter of our country's total population. History has demonstrated that the baby boomers redefine each stage of life as they pass through it, and in every prediction this "redefinition process" will continue as they progress through their senior stages of life. It's clear that the sheer volume of baby boomers now entering this stage of life will have a significant impact on our medical practices for the next two decades.
The definitive Merrill Lynch new retirement survey found that 81 percent of baby boomers plan to continue working beyond the age of 65. The collective financial power of the baby boomers between the ages of 50 and 60 already is twice that of today's 67-year-olds, and continuing to work will provide them with even greater resources as they age. As a result, many employers and health plans are going to be placing a greater responsibility for paying for medical treatments on these patients. This growing segment of older, active patients will become more involved in determining which doctors they see and what care they receive. In addition, as I mentioned, they also will have greater resources for paying for their health care.
This is a group of patients that all doctors will want to attract to their practices. Baby boomers are vigorous. They're taking on new jobs, relocating, going back to school, starting second and third careers, and targeting the health issues of aging. The baby boomers will take time to seek out the "right doctor" - one who can meet their specific needs. Health plans and employers already are planning to make it increasingly easier for patients to find the best doctors by providing information that will allow them to compare physicians with respect to such matters as quality of care, patient satisfaction, treatment outcomes and fees. For that reason, it will become important for doctors to be knowledgeable about evidence-based medicine and understand which factors help to measure physician quality and patient satisfaction. Working through their associations, naturopathic physicians should be actively involved in the process of building databases containing evidence of treatment outcomes for their specialties.
The Baby Boomer Impact
According to Business Week, "Baby boomers do not want to be 25 again. They are comfortable with aging, but they want to look and be healthy." This desire opens tremendous opportunities for naturopathic services. As we also know, not all the boomers are active, most significantly because a large subset of this group is overweight. Many are even obese and might already be suffering the complications of obesity, such as type 2 diabetes, high cholesterol and hypertension. These patients and the general population are in critical need of preventative naturopathic services.
We can now see that the pendulum might swing in the opposite direction for insurance coverage and the way patients are treated, if the baby boomers begin to dictate to the insurance industry the type of medical care they are looking for and the fact that they're willing to pay for a portion of this care - something they were reluctant to do until recently.
We should discuss here one of the travesties that has occurred in the alternative medical insurance realm: the advent of companies that sell panels of alternative care providers to large insurance companies. These companies ostensibly market groups of alternative care providers, stating that they will assure quality of care and keep reimbursement levels low to the carriers. Large insurance companies have signed contracts with these alternative medical networks to help market more of their insurance plans by offering alternative care in their insurance products. However, the majority of these companies have severe restrictions on the amount of visits and reimbursement levels provided to the patients on a yearly basis. It's not uncommon to find, in the financial reports of these alternative network companies, that their administrators are receiving six-figure incomes and periodically awarding themselves seven-figure bonuses. Meanwhile, they are paying the alternative care practitioners a small fraction of the billed amounts for services rendered.
Many of these alternative care panel groups make practitioners sign contracts stating that they will not balance bill the patients for office visits or procedures, and that they cannot make disparaging remarks against the carrier because there is a gag order in the contract. An astute physician should be very wary after reading a contract that has a gag order in it prohibiting a physician from making remarks to other physicians or beneficiaries regarding the operations of a company or its reimbursement. In my opinion, when any contract abridges our freedom of speech, it shouldn't be signed.
Currently, there is discussion in the naturopathic profession regarding being included in the federal Medicare/Medicaid program. I think the profession should analyze what currently is happening to those providers who already are participating in the Medicare/Medicaid system. Reimbursement levels are dropping on a yearly basis, and the amount of paperwork and charting necessary to support your evaluation management for claims is extremely onerous. Mistakes made in coding, even by your staff, can be characterized by CMS as fraud. Audits and retrospective audits can be done on your patients' charts and your billing. If an error was made in innocence regarding a coding number, it's possible they would sanction you as a criminal for that activity, with stiff fines and penalties and possible future exclusion from the program.
I have a dual practice as a podiatrist and a naturopathic physician. The podiatry profession, along with the other medical professions, spends tens of thousands of dollars a year or more in lobbying efforts to prevent reduction in reimbursement for podiatric procedures and exclusions from certain types of health plans. In spite of our success as podiatrists in the antitrust case brought against 11 insurance carriers in Oregon, the industry constantly looks for ways to delay payment, downcode procedures and bundle independent procedures to reduce reimbursement.
A federal suit in Florida recently was settled in which more than 600,000 physicians filed a class-action suit against several large insurance carriers such as CIGNA, Humana and others. The court, in the course of the case, found that these insurance carriers had constructed computer programs specifically geared to delaying payment, reducing reimbursement, downcoding procedures billed to their respective companies, and bundling procedures into one code that should be, and should have been, paid as independent procedures.
It would behoove the naturopathic profession to learn a lesson from the struggles the podiatry profession has gone through (and now all the medical professions are going through) when it comes to being covered by insurance for their services. It's truly a double-edged sword when you would like to help your patients medically and financially, and bill their insurance company for your services, but have to fight with that same insurance company to get paid for those services in a fair and equitable fashion.
One last thought for those naturopaths who want to increase their participation in insurance plans. The cost of doing business in your office will increase dramatically because of the amount of office staff needed to process insurance forms, obtain prior authorizations for treatment and answer the questions of irate patients whose insurance companies have not paid for their services.
If we, as physicians, are ever going to gain control of our practices, our lives and our reimbursement, we need to confront the current insurance system in the U.S. Unfortunately, most physicians live in fear of insurance companies, and CMS physicians can be greedy and want every possible patient promised by every possible insurance carrier and plan available. However, if we are going to recapture our independence and restore the close doctor-patient relationships that were prevalent prior to this insurance debacle, we will need to demonstrate some testicular fortitude and send letters of resignation to these plans. The insurance plans without providers would have to either capitulate on their reimbursement schemes or declare bankruptcy, because no patients or employers would pay insurance premiums if providers were not available.
I opted out of Medicare approximately five years ago, after having been a member provider since 1972. After I resigned as a participating provider, I saw my income increase. I have more time to devote to patients who pay cash and I can give them value-added service without having to worry about whether their insurance will pay for it.
If the above scenario were to happen, with 80 percent or more of the physicians sending a letter of resignation to insurance companies, a crisis situation would occur within the federal government. Our elected officials would see that there was something drastically wrong with the current system and would have to come up with a solution once and for all for this health care crisis.
In the meantime, naturopathic physicians have the same opportunity dentists had to create financially successful practices: by billing fee-for-service to the patients directly. This system has worked for the dentists since they were excluded from the coverage by Medicare back in the mid-'60s. As we know, some dental insurance plans are available, but once accepted, the double-edged sword comes unsheathed and the battle begins between providers and payers.

About the Author: Dr. John Hahn is a graduate of Sacramento State University, California College of Podiatric Medicine and National College of Naturopathic Medicine. He has operated a private practice in Oregon since 1972, with special interest in podiatric surgery and podiatric sports biomechanics. He added naturopathy to his practice in 1993. He has lectured at various naturopathy and podiatric conventions and has been published in numerous journals. Dr. Hahn can be reached at jmhahn2@verizon.net.