One Utah

About a month ago, I wrote about my experiences seeing a doctor on the weekend - that clinics covered by my insurance were no where near my house and so forth. The saga of that visit has at long last moved towards its final act.

My insurance requires that all claims be submitted by the last day of the plan year - that being June 30. Any claims not submitted by June 30 can be summarily rejected. At the time of my visit, I was very clear with the clinic that the claim had to be submitted. I even offered to take a copy of the bill (if they could produce one) and submit it myself. They said it was not a problem, that my claim would be submitted the first business day after my visit.

This was in fact not the case.

The clinic I visited uses a third party biller - IOW, they provide the services, collected the co-pay and send the bill to someone else, who codes it and then submits it to my insurance company. Ten days after my visit, the bill had not been received by my insurance. I called the clinic to talk to the person who does the billing. I called the third party processor and explained the situation - emphasizing this must be submitted by June 30. They responded by (wait for it) telling me they would submit the bill the following monday.

You know what happened. Nada. Zilch. Zip. Zero.

I called again, explained again. While I was on the phone, the woman I was talking to said there were no notes on the bill about the deadline. I was fortunate and was able to say the date, time and individual to whom I spoke. I insisted the bill be sent to my insurance company that day. I provided her the fax number. She faxed the bill at that time.

Now here’s the thing - my insurance uses a third party processor, to whom we sent the bill. So my insurance company’s processor received the bill, reviewed, and submitted to my insurance who, to the best of my knowledge, on thursday of this week, sent the payment to the clinic, as provided by my insurance plan.

Now, the broad point here is simple: This process is way to complicated. Four separate organizations were required to pay the bill for my visit to the doctor. At any time, three of them could have denied payment, claiming my visit was unnecessary, creating a bureaucratic roadblock. Fortunately, that did not happen. But if you wonder why American health care is so expensive, you need look no further than this situation. Health insurance in the US is vastly complicated by huge private bureaucracies designed to make money for private insurance companies. The jobs of these bureaucrats are to deny payment for services, to keep our insurance premiums in the pockets of private companies. Results have become an increasingly complex system through which providers and patients must navigate, and in which they are at a disadvantage. From a simple economic basis, the US health care system had become a competitive liability. We pay more for health care than any other developed nation, we pay more per person, we get significantly worse outcomes.

Other industrialized nations have figured out how to provide health care to their citizens. Each of those systems has its strengths and its weaknesses. But none of them leave huge chunks of the population uninsured, as does our system. For Christ’s sake, Cuba apparently has a more health care system than the US. That’s insane.

Canada has a single payer system, administered at the provincial level, in which doctors and hospitals are private but the government acts as the health insurer. The UK has a nationalized health care system, in which the doctors and nurses are employees of the government and hospitals and clinics are owned by the government. I believe France has a single payer system. Germany has a system close to what the Clinton administration proposed in the 90s - in which a variety of options for health insurance including private cooperatives and government programs are available to consumers.

For sheer simplicity, I agree with Krugman - health care may be complicated but health care insurance is not. The various proposals floating around right now are all designed to do one thing - reduce opposition by the health insurance industry. If they have the effect of making getting health care less complicated, I’m in favor of it. But I think in the long run, the US will end up with a single payer system, probably one administered at the state level and open to all citizens and legal residents. The result will be a massive shift as third party billers and processors whither away, as huge insurance companies fade. It will be a massive reform and one that terrifies a lot of people. But as a matter of national policy, of economic competitiveness, of overall well being of US citizens, I think it is an inevitability. Failing to do something positive on health care will only create more problems for the US. I keep reading the statistic that $1000 of every GM car’s cost is for health care. Many private companies are increasingly finding the cost of providing health insurance to their employees punitive. Change is coming - the system is in active breakdown. We have a choice now, to manage what comes next to get the best outcome for the most people or to just sit back and hope it isn’t too awful.

This entry was posted Sunday, June 29th, 2008 at 7:54 am and is filed under Healthcare. You can leave a response, or trackback from your own site.