Is it a patient’s responsibility to know if their insurance covers the visit or should the office manager or biller mention it?

A friend recently went to an ENT specialist. With the initial office visit the office manager didn’t say anything about requiring a referral.

We have all had something happen with our insurance when we go to a provider for the first time, or when we change insurance. The entire insurance coverage process is complicated and confusing. Do you need a referral? Is your copayment higher with this provider? Is this provider in or out of the network, and what are the implications of it all? Unfortunately, the ability to call and get their answers from the carrier cannot always provide consistency. The provider of service, who ultimately (usually) is the submitter of the claim, can obviously facilitate some of the answers, as their reimbursement is going to be either expeditious or delayed as a result of how the process is followed.

We all have made the call for a new appointment. We all know that when we are a new patient, there will be forms to complete, and insurance to present. The person on the phone taking that initial information “always” asks what type of insurance you have, and gets the details. As a general consumer, if a referral is needed, you just may not be aware. So how about this scenario:

A person goes to a specialist. The specialist is not in network, and the patient did not get a referral from her primary doctor (who also turns out to be out of network). The patient calls the specialist to make the appointment, gets it scheduled, provides all of the necessary information for the visit, including all of the insurance information (and a copy of the insurance card upon arrival). A copayment based on the specialist (and written on the card) is paid. The visit transpires, the patient schedules a follow up and a procedure that is needed as a result of the visit, and life goes on.

Fast forward nearly three months, and the patient gets a nasty call from an office manager stating that the claim for the service was denied (the one that occurred three months prior) because there was no referral. There was no discussion about needing one, and of course three months later who would think it was an issue. The office manager berated the patient about the fact that she should have known about needing one, since it is her insurance and her responsibility to know coverage. Yes, we would agree that there is some personal responsibility here, but the office knew the plan, knew there would be out of network issues, and likely knew about the referral matter (it is an HMO, they all work similarly so the argument of the provider is not in network and does not know the nuances is a scant argument). The patient had only recently taken this insurance on the Exchange, and had previously been paying COBRA, so she was happy to have something that was not costing her a mortgage payment.

The kick to this tale is that the insurance plan told the patient that she merely needed to make an appointment with an in-network primary care doctor, have the visit and get the referral. With the referral, the provider can go back 90 days prior to and resubmit the claim. So essentially, the entire process is (1) a work around, and (2) an additional cost, since she will have to see an in-network provider who will bill both the insurance for the visit and the patient for a copayment. The specialist was required as her out of network primary wanted her to see the specialist, so a visit and a claim were already submitted for this evaluation.

The moral of the story is that sometimes we make the process so much more complicated that it has to be, and we wind up creating systems that actually cost more than actually save, which is the entire premise behind value-based care.

After googling for a few minutes for local general doctors, the patient booked an appointment and the results? “It was pretty seamless, he didn’t even look at my tonsils and wrote the referral.”

So what makes this not be healthcare fraud? Is it Corruption (kickbacks and bribery)? We have written about doctors unlawfully paying for and/or receiving payment for referrals. Abuse is an obvious byproduct when referrals are made for services that are not needed, such as MRIs, X-Rays, prescription drugs, etc.

How are the kickbacks or bribes found? Are bogus referrals enough? Short answer is no. in order to prove a case of this nature, a quid pro quo but be established. Provider paid for or received something of value.

Everyone involved in the healthcare continuum should care about kickbacks (except those who are obviously engaged). Honest providers can be at a disadvantage due to the anti-competitive nature that exists when a kickback is paid. The payor community is concerned about paying for items, services and procedures that may not be necessary, since things are paid for on a per referral basis. Sometimes patients do not care, since the providers taking the kickbacks are already involved in illicit practices, the copayments are waived, and they can become both unwitting and witting participants in the scheme. Regardless of what anyone believes in the public, kickback cases are difficult matters to investigate from an SIU perspective. SIU units for a payor have a limited ability as to what they can request, review, investigate and opine upon. Kickbacks will always be a problem in the healthcare industry, since most of the time, they transpire behind closed doors under the veil of secrecy.