How health insurance hurts care

The Center for Social Policy of the University of New Mexico, fulfilling a grant from the N.M. Legislature, has just released “Analysis of the Medical Claims and Billing System in New Mexico,” a 35-page report of focus groups of claims professionals and clinicians.

Stunning title, right? You’re thinking, before you skip this report for the funnies, “What could be more tedious?” Now is the time to remember your last visit to your doc, or to recall a story by a friend or relative with a perilous medical condition, describing their struggles to gain treatment covered by their insurance.

That boring title actually carries the flavor of life-or-death decisions. All of us will benefit from paying attention.

Authors Melanie S. Sonntag and Gabriel R. Sanchez had gathered 31 persons engaged in medical billing in eight New Mexico counties - rural and urban, north and south. To explain what they learned from their sources, they deliver a glossary and a superb graph with dizzying arrows to sketch what a mess our society has created to reimburse hospitals, clinics, pharmacies and doctors.

Just looking at the graph on Page 8 tells us that the story we’re about to learn isn’t pleasant.

Our authors deliver conclusions in bold, red-type headlines. The first head? “Billing and insurance related tasks are time intensive and complex.”

Every medical office must employ clerks to complete billing statements to insurance providers. Nurses labor for as long as a day to obtain pre-clearance for medical treatment. Moreover, doctors and nurse practitioners find that they can spend 15 to 20 minutes with a patient, but an extra 10 to 15 minutes on documentation.

“While the clinicians agreed that charting is a necessary and important component of their work they said that the requirements for insurance on how charts are written add an unnecessary burden that feels like busy work that does not lead to improved care,” the report reads.

Medicare and Medicaid are especially onerous, requiring a report that includes five different steps.

Here’s an arresting red-letter box in the report: “Billing is not black and white. If you’re coding according to the book, it won’t work. If you follow the book, no one gets paid.”

Here I recall my own experience with a Las Cruces hospital. I have aggressive prostate cancer, as determined by a biopsy. My urologist needed to know if cancer had spread outside the prostate. He ordered a PET scan that uses a radioactive tracer to show presence of cancer cells. Before the scan, the urologist’s clerk called me to ask if the hospital had told me that Medicare won’t cover the procedure.

I called the Medicare hotline. The representative reported that the procedure was covered. When I told the hospital clerk that Medicare assured coverage, she said that they had a machine that reads the doctor’s order and lights red or green to indicate Medicare reimbursement. I would have to guarantee payment to receive the scan.

With the clerk’s report of the code the hospital used for my diagnosis, I called Medicare again and spoke to yet another woman. I gave her all the details of my condition and the information from the hospital. She went away and came back and gave me a different code that should be used. (I figure Joe Biden and I share that code, but that’s not to say Walter Reed ever has any use for codes.)

The hospital didn’t welcome my help. They declared they would take a meeting, and I should wait for their determination. The wait had no good end. I would have to pay $9,000 for the PET scan. I went to El Paso, covered by Medicare. Meanwhile, the Las Cruces hospital had spent hours on the issue, and I guess more than one patient has ended up with a $9,000 debt.

“Speaking on formulary, especially the clinicians we spoke to observed that this severely and adversely impacts patient care. They explained that suddenly, a certain prescription, infusion or treatment is no longer covered by insurance even if the clinicians had observed success of said treatment.” The result? The doctor must spend hours getting authorization from the insurer or exploring a change of treatment.

The facilities the respondents worked for had neither enough staff nor infrastructure to process the claim load. That leads to high turnover of frustrated, overworked employees. Sometimes at the end of their minimal training, employees seek other work because they have confronted complexity and imponderables, especially in denial of coverage.

Unless physicians spend extra time explaining in detail what their diagnosis entails, insurance companies tend to downgrade the severity of the diagnosis. The physicians cannot leave such description of diagnoses to clerical staff who lack medical knowledge.

There are two shortcuts. One, AI, is too new to judge whether it can save staff time and not cost lives, although doctors are still required for prior authorizations and denials. The second, outsourcing to a third-party contractor, is eloquently described by a contractor: “We don’t care [if you guys get reimbursed]. We get paid regardless.”

And if patients need specialized care? Billing tasks are even more rigorous, eating the clock: “Multiple participants explained that it often feels as though the default answer of insurance companies is to deny claims, meaning that it feels that the process of justifying why patients need care is not only unnecessarily time intensive but also met with a lot of resistance and arguments.”

When claims are returned because of errors or denied because of insurance policy interpretation, the arguments back and forth consume care providers. Medical staff must negotiate phone trees of some insurers for two hours before being placed on hold. Hence, a medical provider may have to pay a significant amount just to get care for patients.

Is it news that operating in rural New Mexico is more challenging than serving an urban area? We now have a report confirming the scuttlebutt. Rural patients often have limited choices for insurance “networks,” “preferred providers” and “managed care organizations.” Rural patients often must travel great distances for even basic services.

Here the red letter head uses a curious adjective: “Rural Areas of the State Face Enhanced Challenges.” As it turns out, one of those “enhancements” is that when a patient fails to pay a bill from a rural facility, that patient is often referred to a collection agent. (Urban hospitals may have charity funds to cover treatment of impoverished patients.)

“As one clinician stated: ‘Clinical decision making is driven by insurance formulary, not individualized patient care.’” Besides the plea for more and better training of personnel to submit claims and for a reduction of unnecessary paperwork, the primary recommendation is to apply a different model to reimbursement of medical expenses. The authors of the report point to the New Mexico Health Security Plan, described in detail in previous Daily Press articles.

By reducing the current need for extensive billing and insurance staff and by putting the emphasis on delivery of effective health care by medical personnel, the Health Security Plan has anticipated this present picture of waste, confusion, and inequitable treatment.

Tom Hester lives in Silver City.