for Thought 2003 - Insurance
Douglas Andersen, DC, DACBSP, CCN
21, number 5, 2/24/03, page 26
Examples of how insurance companies play games.
Happy 03! Shortly after graduation while job hunting,
there were two statements from established chiropractors I once knew that
were so disturbing, I will never forget them. The first one told me, “It’s
a license to steal.” The second one said, “Everyone who walks
in your front door should be worth at least $2000.” It was clear
they both were exploiting the insurance industry. I thought to myself
I would never have the problems they do with insurance because my patients
will either get better or get referred.
I started practicing in 1986. Insurance companies paid my bills on time
and in full. The occasional delay or denial was usually resolved rapidly.
I treated them fairly and they reciprocated. The overall treatment was
fair. That year I went to my first (and last) big chiropractic practice
building seminar. It was three days long and full of the most mindless,
embarrassing, patronizing dogma I had ever heard. One practice builder
told us, “They come in hurt, you treat them ten times over the course
of a month, they get better and now they’re walking out of your
office. What are you going to say when a patient with thirty visits and
eleven months is leaving your office?” Needless to say, asking the
patient to call when they or someone else needs me was not what he wanted
to hear. At this seminar, the lowest form of life was a “pain doctor”
(yours truly). It was my initial exposure to the wellness concept and
the techniques they taught to capture those unused visits. I thought then
and still do now that billing insurance for this type of “treatment”
was unfair, wrong and something I would never do.
After writing last year’s Food for Thought article - “How
to Pick a Chiropractor,” many of the hundreds of emails I received
contained statements like, “I know you are receiving tons of hate
mail, so I thought I’d just write to let you know I agree with you....”
What would be a great surprise to many of those who wrote (both pro and
con) was that a full 50% of the responses I received were positive. This
brings me to this year’s topic.
Memo to the Insurance Industry
There are plenty of chiropractors who do not overtreat, overutilize, or
overbill. They don’t like chiropractors who do any more than you
do. I personally applaud all the tactics you use to make their life difficult
and I am guessing many of those chiropractors who agree with my ideas
would feel the same. However, you HARM YOURSELVES, YOUR POLICY HOLDERS,
AND THE WRONG CHIROPRACTORS by assuming everyone is out to get you. You
(the insurance industry) should do everything you can to treat legitimate
chiropractors and their patients fairly. You know who they are because
you have their practice profiles. And, in the cases where a profile is
out of the norm, you know how to investigate to find out whether the practitioner
is legitimate or not.
The following is an example that could undoubtedly be multiplied many
hundreds of times by many chiropractors; Last year, I had a patient enter
my office who had been injured in an automobile accident. He was treated
on five occasions and responded very favorably. He was released with a
total bill of $580. The insurance company did not pay my bill. My office
made numerous calls, and sent eight statements. Finally, after four months,
we received a check for $360. My office manager called and was told we
overcharged the insurance company. (As an aside, she will often tell her
family, friends, and patients, “Before I started working for Dr.
Andersen, I had no idea how poorly insurance companies treat doctors.”)
I then had my receptionist call, wait through the voice mail, go through
the screeners and finally get a supervisor on phone. I then picked up:
Dr. Andersen: Do you think many chiropractors treat people
Insurance Company: Yes.
DA: Do you think many chiropractors treat people too
DA: Do you think many chiropractors charge too much?
IC: Sir, what is this? Sir, please get to your point.
DA: How many 30 mph rear end accidents into a stationary vehicle have
all injuries resolve in under 30 days?
IC: Aaaah, not many.
DA: How many moderate impact cases resolve with less
than ten treatments?
IC: Not many.
DA: How often is a bill for this type of accident less
DA: Then why are you punishing me for resolving an injury
in less than 30 days with fewer than 10 treatments for a fee of less than
IC: Your charges exceeded usual and customary.
DA: What is reasonable and customary?
IC: That is information we cannot disclose.
DA: Then I must ask you, WHAT DO YOU WANT? You just complained
about excessive treatments and excessive billing when I got a patient
better for under $600 and you still want to treat me like a criminal and
punish me. The reason why the patient got well was (1) he was highly motivated;
and (2) he received quality treatment, including a lot of soft tissue
work. What would you have wanted me to do? Give you a usual and customary
charge of $50 (?) for a pop-and-go and treat him 25 times? I get the feeling
you think either 1) every patient magnifies his or her symptoms or 2)
every bill – large or small is padded.
Is that what you think?
DA: Well I sure hope this call is recorded for “quality
control”! For everyone who is listening, I don’t like dishonest
patients anymore than you do. But the good news is your industry has made
this whole process so miserable, most insurance patients I see wait too
long to start care because they don’t want the stress you cause.
IC: (long pause)
DA: I do not understand why, when someone does a good
job, we still get penalized. I did $580 worth of work and I expect to
get $580 worth of reimbursement. Do you expect me to charge $50 for a
IC: (long pause)
DA: Why won’t you just look at the bottom line
which was a much smaller bill with much fewer visits than your statistics
dictate for an accident of this type and realize that you are upsetting
an honest patient and a good chiropractor?
Five months after
the patient was released, the company agreed to pay my bill in full. Question
to the insurance industry: How much interest income do you make yearly
by stalling on almost every bill you pay?
Here is another example (I have so many it is hard to pick): A woman with
neck pain entered my office for treatment and examination. We called the
company for whom we were a provider (membership on their panel included
a reduced fee schedule) to confirm benefits. One of the questions my staff
asked was, would x-rays be covered? Their answer was yes. I then examined
the patient and told her, based on my findings, I thought we should be
able to resolve her problem in less than five visits. I also told her
I was not going to x-ray her unless her response was unsatisfactory. She
appreciated my attempt to save her the exposure to radiation. (I also
felt the insurance company would appreciate my attempt to save them the
cost of x-rays.) After four visits, her improvement was only 20%, so I
took an AP and lateral cervical x-ray. (Her problem area was C6-C7.) We
saw some DJD at C6 C7 which explained the slow response. After six additional
visits, she was released permanent and stationary with full resolution
of all pain. Our bill was submitted to the insurance company and was rejected.
The reason was that our x-rays were unauthorized. We resubmitted the bill,
informing them that we were told that we could x-ray. They gave us a second
denial, saying that we were told we could x-ray on the first visit, but
since we did not x-ray on the first visit, we had forfeited our authorization
to x-ray at a later time without specific authorization. After a flurry
of phone calls, we then submitted another appeal. This time, we were rejected
because we DID NOT TAKE ENOUGH X-RAYS. The rejection letter stated that
if we were going to take x-rays of the cervical spine, we should have
taken at least three views. When my staff showed me this rejection letter,
you can imagine what my reaction was. We made some phone calls, got through
to a supervisor who then transferred me to a staff doctor. I told him
my story about how I was trying to save the patient exposure to radiation
and his company the cost of x-rays. He then began to read me some rules
about the amount of views required. I continued to argue with him, after
which he stated that I should write a formal appeal report. I spent the
next hour writing the report which we sent in and, lo and behold, six
weeks later, finally got paid. Therefore, it was six months before I received
payment for an examination, two cervical x-rays, and nine treatments which
totaled all of $300. I then quit this company shortly thereafter. When
they asked why, I stated that working for substantially reduced fees was
already a sacrifice and I simply could not afford to spend the additional
time and money required on every single case of every single policy holder
to collect the money I earned months ago. I told them I would not blame
them if I had seen this patient 56 times for her symptom complex. But
it is unacceptable to be jerked around for months on straightforward cases.
It currently takes more labor, more phone calls, more paperwork, more
re-submissions, and more appeals to collect smaller reimbursements from
the insurance industry. No one likes to be voice mailed, fine printed,
stalled, delayed and treated unfairly. I realize that the insurance industry
has more money and more power than the healthcare industry. I realize
we cannot compete with the money you donate to our elected officials;
however, it is this author’s opinion that the insurance industry
should take a close look at how they do business. Treating honest patients
and doctors like thieves increases both animosity and anger. It creates
an environment that breeds contempt and causes everyone to have a “get
even” attitude toward your industry.
Finally, when patients see that their premiums continue to rise and the
doctors see their reimbursement continue to decline, do you think we believe
you when you complain about the increasing cost of chiropractic care?
What do you think we say when you cry poor while your profits and reserves
indicate the opposite? What would you do if you were a chiropractor (or
patient) and the insurance industry treated you like you treat us?
There are many patients and many chiropractors who are trying to do the
right thing. It would be nice to see the insurance industry reserve their
“usual and customary” treatment to those who deserve it.
A final thought…
Imagine you go to the local market, buy a bunch of groceries and then
tell the clerk you will pay what you want, when you feel like it. Payment
will probably be less than the bill. You tell them they may need to call,
write, fax and email over the next few months or you will forget to send
the reduced check (without interest) altogether. Now, is that fair?
E. Imperial Hwy.
Brea, CA. 92821
2004, G. Douglas Andersen, DC, DACBSP, CCN, 916 E. Imperial Hwy, Brea,
CA 92821, (714) 990-0824