The Games Insurance companies play...

As someone who works in the healthcare field it can be very frustrating dealing with patients and their insurance companies. Here are a few things that I have noticed that are being done or not done (and some rhetorical questions)...

1. Why does it matter to the insurance company where an exam test is performed? I currently work in a outpatient clinic; there is a insurance company that will pay the exam cost when a MRI is done in the building that I work in. They will not pay if the same exam is done at the hospital location. Keep in mind that the customer is NOT being admitted into the hospital, the same equipment is being used, the same doctors are performing the studies, the cost are identical and the buildings are even attached. This insurance company just wants their customer seen in the outpatient center even if it means that they will have to wait longer to get an appointment.

2. Why do insurance companies refuse to pay for routine testing needed to make a diagnosis? I learned a long time ago that you cannot use the phrase "rule out" when submitting a bill to a insurance company. For example, if you use the diagnosis "herniated disc" the insurance company will probably pay for the exam- but add the words "rule out" to herniated disc and they will not. I have never been able to figure this out-- if anyone was certain that there was a herniation they could proceed straight to treatment. Sometimes you have to "rule out" things.

3. Why make people be admitted into the hospital for studies that can be done on a outpatient basis? This is a situation that happens all to frequently... Someone gets sick and needs a lot of expensive test-- the person's insurance company scoffs and refuses to pay. But doctors and hospital administrators are smart and have figured a way to beat the insurance company at their own game...just admit the person into the hospital and the insurance company will pay for whatever the patient needs. So, in addition to paying for the test and procedures that could have been done as an outpatient the insurance company gets to pay for a hospital admission also. I cannot image a more effective way of wasting time and money.

There are huge bureaucracies and seemingly endless red tape that must be navigated for a process that could be fairly simple. When someone is sick or injured they deserve care and compassion; from my point of view most are not receiving much from the insurance company whose business it is to provide for their patients when needed.