Bemusements

Dealing With Insurance Companies (aka lessons in terrorist negotiations)

by Barbara Kapetanakes, PsyD. on 04/01/15

I received an email this morning from a mother. I had tested her child a couple of months ago. I clearly communicated my fee, which she promptly paid, and gave her paperwork for her insurance, which she must have also promptly submitted.

In her email she informed me that I should have charged 30% less than I did, as the Explanation of Benefits from her insurance company indicated that they regularly "negotiate discounts with providers and facilities to save you money."

All this would be fine if they HAD negotiated a fee with me, which they had not. If I had an "in-network" contract with the company, they would have a right to set the fees, as the provider signs a contract to accept a (usually much lower) fee. But an out-of-network provider can charge whatever the market can handle. As I put it to this mother when I responded--I can charge a million dollars if someone is willing to pay it. The insurance company can still put a cap on what they will reasonably reimburse, but they have no right to insist I accept a lower fee when I have no contract with them.

I suggested that this mother call her insurance company and remind them that I am OUT of network, and therefore they are not ALLOWED to set my fee, and also suggested that I might report them to the State (the Attorney General deals with issues like this).

I decided to write this blog today to provide some information. Most people have only a general sense of how insurance works, and know neither the finer details nor HOW they do business (it's like dealing with the Taliban, quite frankly).

If you go to an IN network provider, that provider MUST accept the in-network fees, and you ONLY have to pay whatever in-network co-pay is required. The provider is NOT allowed to balance bill you, but must accept the contracted rate. For example, if my usual fee is $100, but United Health Care pays a contracted rate of $80, then I can ONLY make $80 on that session. If your co-pay is $10, then you pay that, United pays 70 (total of 80) and it would be illegal for me to charge you the additional $20 to make it to $100. I would have signed a contract with that insurance company, and the fees would be clear to me. Aetna may pay $70 or $85 or whatever their fees are set at, and I would have a contract that stated those fees clearly. Each insurance company has their own rates for each specific procedure code. I could wish they paid more, but I cannot get any more.

For out of network providers it is different. We set our own fees, and you can choose to see us or go to someone within your network if going out of network is not affordable. I can also CHOOSE to lower my fee for someone down on their luck, or who has no insurance, but that is MY choice, not something mandated by an insurance company unless I have signed a contract with that company. The insurance companies still set caps (reasonable and customary fees), and that's fine. We can't expect the insurance company to pay for fees that are well above reasonable and customary (although how they define reasonable and customary is a blog for another day). However, if you have chosen to see a professional who comes highly recommended, even if he or she is expensive, then that is your choice, with the understanding that your insurance may only pay a small portion.

The same way that I am not permitted to balance bill a patient who sees me as an in-network provider, the insurance company is not permitted to decide what my fees should be. This poor mother who got a notice that I owed her 30% of the fee back because a lower rate was "negotiated" is now confused and probably upset with me or sees me as "greedy" in some way. This would not surprise me. If I returned money every time an insurance company tried to put one over on us I'd be broke. It is not up to the insurance company to decide what I can charge, even if it is up to them to decide what they will or will not reimburse.

Insurance companies are panicking because President Obama has told them that they have to cover certain things such as yearly physicals and mammograms (for FREE). The Affordable Care Act eliminates things such as lifetime maximums and lowers the out of pocket costs we can expect to pay. Because so many people declared bankruptcy due to medical expenses, the ACA aims to stop that bleeding. Make no mistake, insurance companies are multi-billion companies and their executives make millions. They are seeing the changes and don't like them. So they look for all kinds of reasons not to pay bills. They have also increased many people's deductibles (not a terrible trade off for no longer having a lifetime maximum of coverage. Truth is, a bout with a life threatening illness like cancer can eat up that lifetime maximum in 12 months).

I am in-network for only one private insurance company as well as a Workers' Comp provider. The private company is about 6 months behind on paying claims. And Workers' Comp often takes weeks if not months to approve service and pay claims. This is what we providers are used to, and we deal with it. But neither we nor our patients should have to deal with outright lies written up on an EOB stating that someone overpaid. My patients don't deserve this runaround, and I have to pay my bills and put food on the table, and I have set the reasonable and customary fees for my expertise and geographic location, and I have a right to do so in order to make a living.

I have been on the other side of this as well, when I had a test in a hospital that my insurance company refused to pay for. I never really understood what the problem was except that they would have paid for a more expensive, risky procedure (eg, general anesthesia rather than Lydecaine), and/or if it were in a different area of the hospital building (eg, in-patient/out-patient/ambulatory/etc). I spent a solid year fighting the insurance company on this issue and finally worked out a payment plan with the hospital. I still remember Melinda's voice, as we became great buddies during that time...."Hello, this is Melinda from accounts receivable"......

We all know we have to beware when buying a vacuum cleaner, a blouse, a home, to check freshness dates on a container of milk, etc. But when we are sick the last thing we should be saddled with is getting the runaround from our insurance companies, but it happens. Caveat emptor.

Comments (0)

I know it's true, oh so true, 'cause I saw it on TV......

by Barbara Kapetanakes, PsyD. on 01/26/15

In the news this week is an outbreak of measles that can be traced back to Disneyland. Dozens of people in 11 states are suffering with the disease right now and I'm sure there are more to come.

In 2000, the US declared measles eradicated. Decades of vaccinations had led to measles being a thing of the past. Around that same time a doctor published a study declaring that vaccines could cause autism. Autism awareness went up, diagnostic criteria changed causing an increase in the diagnosis of autistic spectrum disorders, and people panicked. Despite the fact that the original study was never replicated, despite the fact that it was proven that the original study was based on fudged data and questionable subject sampling, despite the fact that measles and other "eradicated" diseases can be fatal or crippling, an anti-vaccine movement ensued.

And now, as of this writing, 68 people have measles.

The Internet is a wonderful thing. We can find information instantaneously, we can connect with like-minded individuals, find support, etc. It is also a very dangerous thing, since misinformation can be passed on as gospel and spread like wildfire. No scientific research has ever found vaccines unsafe for the general population. Let me say that again. NO scientific research has EVER found vaccines unsafe for the general population. In fact, it is the opposite--through mass vaccination efforts we have eradicated diseases that plagued our ancestors only a generation or two ago. Expectant mothers got rubella and gave birth to children who were deaf, blind, mentally retarded, or a combination of all three. Polio crippled a future president. In 2015, we thought we had nothing to worry about. But we do.

Be very careful when reading information. Check your sources. A doctor who lost his license to practice and a former Playboy model and comedian are probably not the best places to get medical advice. Click those links that lead you to the actual research papers. Read the actual research. What journal is it from? Who wrote it? Has it been replicated or disputed? THEN make your (now informed) decisions.

People die of measles. If you want to choose not to follow your doctor's advice, at least do it armed with information from reputable sources.

Comments (0)

Harvard Ain't Everything

by Barbara Kapetanakes, PsyD. on 01/15/15

Tom Hanks had an op-ed in the New York Times the other day hailing President Obama's push to help provide easier access to community college to American workers. Mr. Hanks talked about his own experience at community college--how much he felt he learned, how it prepared him to attend a four-year college, and the great teachers he had.

His op-ed was timely, as many 12th graders are anxiously awaiting acceptance letters from their top choice colleges, and those who don't get into the "better" schools will be left feeling disappointed. I often work with the kids who end up at community college to start, or who go away, weren't really ready for the rigors of a 4-year college and life away from home; they come back, take some classes at community college, and venture out again a year or so later. Even though there is nothing wrong with these scenarios, many kids, particularly those in affluent suburbs, are made to feel that community college is a waste of time ("13th grade") or that they are never going to amount to anything if they start at community college. Whether for maturity reasons, financial reasons, or having poor grades in high school, community college is the best choice for many young adults.

I have taught as an adjunct at many local colleges, including the community college. While, yes, there may be a higher percentage of kids "goofing off" or ill-prepared for college life, there are also many kids who are very serious about school and see community college as a stepping stone. In particular, I've had students studying nursing in my classes who are incredibly dedicated, since they know that nursing programs are very competitive and nothing but a 4.0 will open doors for them. I had one student move here from a foreign country eager to pick up the profession she enjoyed back home. This required her to meet educational requirements in the US. She worked hard, completed her courses, and then went on to a prestigious program in her field. I've seen middle aged students who want to change careers or advance in their current job, elderly retirees auditing classes just for fun, and blue-collar kids hoping to be the first ones in their families to finish college. The goof-offs eventually drop out, either returning when they have more maturity, or going into a career that doesn't require college. The good students go on to find their success. Tom Hanks clearly didn't do too badly.

I, myself, have taken art classes through the community college for fun and personal interest, and have met other individuals from all walks of life who take advantage of such programs year after year, paying the more than reasonable tuition simply for the pleasure of drawing or painting once a week. You're not going to see that at Yale.

Community colleges serve a purpose. While it's fine to dream of the "big time," starting out small in no way prevents you from making it big later on. Someone who will be successful will find his path, community college or Harvard. As long as you are moving forward, you are moving in the right direction.

Comments (0)

On Social Media and Tolerance

by Barbara Kapetanakes, PsyD. on 01/07/15

As a therapist, I'm used to having conversations day in and day out that often touch on issues that are hard to talk about. I also have people in and out of my office whose opinions may differ from mine to varying degrees. I won't pretend to be the most flexible, open-minded person in the world (I do hold tight to my opinions!) but I like to think that I can accept that others have different opinions, experiences, and viewpoints from me, and that in general I try to understand why they have those opinions, even if I don't agree with them, or think they are wrong. In other words, I may not like your opinion, but you're entitled to it, and you're even entitled to voice it to me. I'm pretty sure that's why we started this whole country in the first place.

That being said, I'm quite struck by the lack of tolerance of others that I see today. Rather than social media and the Internet exposing us to more varied opinions, it seems that all most of us really want is for people to echo our opinions and not veer from whatever party line we prescribe to. I've been "unfriended" more than once for asking a question or stating a fact (not necessarily even expressing an OPINION or ARGUING with the initial poster). As someone who often has tough conversations with people, who has to keep an open mind in order to demonstrate the empathy required of a therapist, this blows my mind. So, if you express something, and I say, "I am not clear what you mean. WHY do you feel that way? I'm not understanding," rather than getting a thoughtful and respectful response I'm chastised for not taking a statement at face value. Meanwhile, in my mind, what I want to do is LEARN from this other person what his or her experience is that might be different from mine, or how that person came to such a conclusion, as I did not connect the same dots and want to understand.

If we spend all our time with people who have the same opinions as us we learn nothing. If we expand our horizons and ask questions, we learn tremendous amounts. When we expect everyone's experience to be the same as ours we invalidate the other person's experience and dismiss it as not worthy of our time. My experience as a white female without siblings growing up in a borough of New York City with my particular family background and economic status is similar to some and different from others. If I presume that we share the same experience because it's MY experience, I am demonstrating an egocentricity that erases the true essence of the other person. I'm saying that another's experience is not worthy of my understanding or even acknowledgement because it is not my experience.

Maybe we should all turn over a new leaf in the new year and try to listen with open minds to what others have to say. We might learn something, make new friends, and have new experiences. Social media has the potential to be a great platform for this, with diverse "friends" and opinions, and the time to think through a response because we are typing rather than talking. However, ignoring (or worse) voices that are different from ours only increases the distance between us as human beings....a distance that is already too great.

Comments (0)

Slowing Down

by Barbara Kapetanakes, PsyD. on 11/24/14

I realized I hadn't written in a couple of weeks, but I didn't realize it had been a whole MONTH. Part of that time I was on vacation, literally, in paradise in the middle of nowhere, but mostly, outside of that, it's just been hectic. Taking time off usually means having a lot to do beforehand, and catching up when you return. Having it be Thanksgiving week right away doesn't help either.

On vacation I read 3 books and took hundreds of pictures. I ate great food, soaked in the local atmosphere, and had time to relax. For the past week it's been back to the grind---and then some! With Thanksgiving just a few days away, things are hectic, but it's important to take time to--it sounds corny, but---give thanks for what we have. Behind me on line at the supermarket yesterday was a man buying at least a dozen turkeys, we joked a bit about the size of his oven, but it was obvious to me, and he confirmed it, that he was involved in some charitable event that was donating Thanksgiving dinners. As I was swiping my credit card for a couple hundred dollars there are so many people, right in our backyard, right in this very rich county, who can't buy a $30 turkey.

I am healthy enough to have enjoyed my sometimes active/sometimes lazy vacation, and to work like crazy when I got home in order to catch up, and still go hiking in the park, go to the gym, for a run, etc, while others are not so lucky. Right now people are getting treated for serious illness, waiting on test results, or otherwise not so carefree as to be concerned about getting in an hour hike before breakfast.

It's so easy to be pulled into the vortex of the rat race on steroids. Time to slow down. I wish everyone a happy Thanksgiving and a good, long, slow weekend.

Comments (0)

« Newer Entries | Main | Older Entries »