01/29/2014    Ed Davis, DPM

Have you recently been dropped from an insurance network? (Carl Solomon, DPM)

Dr. Solomon recently made the following comments:
"Even if we know our negotiated fee, in many
instances we aren't even allowed to collect it. I
pose the question: "In what other business is it
required that instant credit be extended to all
customers, and with terms that are undefined and
difficult to enforce?"

He is correct in that health care providers are
extending credit to patients for services
rendered. That is the insurance game known as
"time value of money" in which there is a monetary
value to the time period from the delivery of a
good or service to the time of payment. The only
reasonable tools we have to mitigate the loss is
to collect deductibles and co-pays up front at the
time of service. Perhaps a percentage of the total
need be added beyond those items in anticipation
of non-payment or improperly reduced payments by
third parties which is commonplace. Insurance
companies often improperly bundle services/charges
then state that the patient is not responsible for
the balance.

I realize that I am opening a can of worms here
but if a third-party adjudicates a claim
improperly then there is a breach of contract that
occurred such that third-party may be improperly
telling us to write off what should not be written
off. Certainly, one should appeal such improper
claim adjudications but that is labor intensive
and adds time to payment, thus financial loss to
the practitioner.

We have lost a significant amount of control over
the third-party reimbursement system but the one
thing we can do as a profession is to establish
reasonable standards as to how claims are to be
adjudicated, including which services are
separately payable. That can be done on the
national or state level via a committee formed.

It is insanity to allow third-parties to make such
determinations. Imagine any supplier who provides
a product being told by the purchaser that for
every dozen widgets provided we will pay as
follows: 100% for the first widget, 50% for the
second, then 20% for the third, the fourth is
incidental to the third and cannot be separately
billed and so on.

Ed Davis, DPM, San Antonio, TX,
ed@sanantoniodoc.net

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