A Health Insurance Nightmare True Story

June 14, 2014

Aaron Monson

We recently had a patient come to our clinic to have a diabetic ulcer taken care of. This is a wound on the outside of the body that has difficulty healing because of the patient’s diabetic condition.

The patient had gone to the hospital, where she was told she had to go to her primary care physician (PCP) first to get the necessary referral authorization that her health insurance plan required. So she came to us per the hospital’s directions. After we examined her, it was decided that she would need to see a wound care specialist to treat the diabetic ulcers. A referral was made to a local specialist that day, and the specialist informed us that they would accept the patient’s insurance. The insurance was notified of the needed referral, and we were told the patient could not see that wound care specialist because that doctor was not on their list of participating physicians.

The insurance carrier was consulted again for a list of wound care specialists that the insurance would cover. It was then determined that the insurance had no wound care providers that were contracted with them. When asked what we needed to do to get the patient taken care of, the insurance sent the patient’s information to a clinical intake nurse to have her case reviewed.  After a few days of waiting on the insurance company, we contacted them again to check on the status of the referral and we were given the name of a specialist they said was a contracted provider. When we contacted this specialist, they informed us they could not see our patient since they only treated pediatric patients. We then contacted the insurance company again to let them know the issue, and were told that was the only provider who was contracted with them.

Finally, after contacting a supervisor in the insurance intake department and the insurance contracting supervisor, we were finally able to get a wound care specialist approved for the referral. Only then did the insurance company inform us that even though the referral was approved, the patient’s benefits for this service type had already been met for the year so the patient would need to pay out of pocket for the care.

The process of finding a specialist the insurance would cover, and filling out the required forms and pre-authorizations took nearly a month. The patient was not able to wait for the insurance company to get the treatment approved and was forced to seek more expedited care elsewhere while we were sorting out the issues. Even after all of the headache, the insurance company refused to pay the bill.

Remember that the patient had originally sought care at a hospital emergency room. What if this patient’s condition had been more life threatening? I wish I could say this was a rare and isolated incident. Unfortunately it isn’t. These kinds of problems are playing out every day in every healthcare setting. So the question is, does health insurance help or hinder health care?

The requirement under the Affordable Care Act (ACA), otherwise known as “Obamacare,” that every American purchase health insurance (or have it provided to them), was supposed to provide healthcare for all. It seems obvious to all of us employed as healthcare professionals that Obamacare will make things worse, simply because health insurance is not (and never will be) health care. Having the one does not guarantee the other. About the only thing health insurance guarantees is that there will always be someone in the middle, dictating how the care transaction will proceed for the patient and the care provider. In other words, someone other than the consumer or the doctor will be making the decisions about their care.

The time is now to leave the traditional health insurance nightmare, and embrace the concept of direct primary care (DPC). DPC is a throwback to common sense, when there were no insurance companies getting in between the patient and the provider. Direct Primary Care is like a gym membership where you pay a monthly fee to access all the primary care services you need, at a price a lot lower than health insurance. If you combine a DPC membership with a low-priced, high deductible health insurance plan to cover catastrophes, you have all your health care needs covered at a substantial savings; and no middle-man telling you or your doctor what to do with your care!