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8080 Academy Rd. NE, Suite A
Albuquerque, NM 87111
Recently I received a call from a patient who had changed insurance. He owned a company and he decided to change insurance to save premiums. He selected a cheaper plan. Although we had a contract with some of the plans of this particular insurance company, we were not contracted with the one he choose.
He called to let me know that the insurance plan was willing to enter into a special contract with our practice so that we could continue to see him and he would not have to pay our self pay fee.
I politely declined. He became extremely irate. He told me that our practice had a duty to enter into this special contract because it was our obligation to take care of him. When I told him that it had been a simple business decision not to contract with the plan he had chosen, he became more enraged. According to him, I should be the one calling the insurance company and negotiating on his behalf.
Unfortunately I spent several minutes on the phone with this patient. They were wasted minutes. He didn’t agree with anything I said. For some reason he saw our practice as an extension of the insurance company. For some reason, the insurance company and our small physician practice were conflated in his mind.
Later I realized that this is one of the big problems with the health industry. People pay money to insurance companies. They get bills from hospitals and doctors they don’t understand. They get an explanation of benefits they don’t understand. Who do they blame? They blame the doctor. I think they blame the doctor because the doctor is the person they see. Actually, the usually don’t blame the actual physician. They blame the physician’s staff. For some reason, they think that the staff is deliberately screwing things up so that they can’t get the services they need.
Nothing could be further from the truth.
Think about it for a moment.
Why would a physician have any power over an insurance company?
The physician isn’t paying the insurance company any money at all. He is getting paid by them. In some ways, which we will get into later, the insurance company functions as a kind of boss of the physician. The contract the physician has dictates what he can and cannot do with respect to the individuals the company insures.
The first thing patients need to realize is that the doctor has absolutely no power at all over the insurance company.
The insurance company is the one with all the power. They decide whether or not to pay the physician. They decide what they will pay and when. They decide what is medically necessary and what is not. Sure some of those decisions are informed by consulting with other physicians. But it usually isn’t your physician. Its someone they have chosen to be on a panel.
The only one the insurance company is answerable to is you. Yes, you are the only one with power. You pay the insurance company. Every month you pay them those premiums. The premiums function as a kind of savings account for your health care. The doctor hopes to get paid from that fund, but he has not guarantee of it. The insurance company gets to decide. It’s not in his interest to do things wrong or jeopardize your care so he won’t get paid.
For some reason, individuals equate the insurance company and the doctor in their minds. And it’s not surprising. More and more the insurance companies are taking over a kind of surrogate doctor role. We’ve had care coordinators and insurance companies call our office or send us letters to make “suggestions” about patient care.
Over the past few years, we've learned how confusing insurance is. Many people do not understand their policies. With knowledge comes power. In this section we've tried to identify some frequently used terms for you. Please remember that each policy is unique, and things change fast so some terms may vary in their meaning with respect to your policy. It's important that you research what your policy covers. This information is just meant to give your some basic understanding to get you started. .