I recently had the experience of being the mother of a child who needed surgery. On July 29, 2015, my daughter, Patricia, had a Supprellin implant placed through an outpatient surgery at Goryeb Children’s Hospital, Morristown, N.J. I am happy to report that Patricia did extremely well and the care that she received at Goryeb was excellent.
Complicated Medical Billing = Unhappy Patients
As the president and CEO of New Jersey Pediatric Neuroscience Institute, Morristown, N.J., and the employer of 15 people, I am very aware of changes affecting patient care, billing and collections. I have had parents screaming on the phone at my staff on several occasions, and I have had to insist that these irate and confused parents come into the office, and sit down with me and my staff over a cup of coffee to review their explanation of benefits (EOBs), charges and payments, so that they can understand how the process works. I have never had a parent leave the office after one of these meetings still angry. In fact, the parents are often amazed by how complex and utterly ridiculous the process of medical billing and reimbursement has become. They are often sympathetic and apologetic for the process of appealing unjustified denials.
We have also helped people apply for catastrophic funds though the state of New Jersey and other organizations when their deductibles were too large for them to meet or when their insurance company arbitrarily decided to pay far less than “usual and customary.” I have referred parents to philanthropic organizations who will help them with mortgage payments, electric and gas bills. In fact, the number of families I have referred for financial assistance has increased dramatically over the last five years. I have seen firsthand how the increased complexity of health care and insurance in the United States is hurting patients and their families.
My Family’s Experience
I know primary care doctors and pediatricians are overworked and often are forced to see several patients in an hour. The pediatricians are busy typing in their electronic medical record (EMR), and are often not looking at the kids. But I look at my four kids a lot, and when I noticed my daughter was starting to develop too soon, I brought it to her pediatrician’s attention. Between the pediatrician, pediatric endocrinologist, pediatric radiologist, hand bone x-rays and blood work, there were about eight different EOBs. I appreciated the prompt and comprehensive care that I received from my friends, my daughter’s pediatrician and pediatric endocrinologist, Lisa Ann Michaels, MD; and Barbara Cerame, MD.
A few phone calls later, after the blood work confirmed precocious puberty, we decided on a Supprellin implant. I saw Mark Kayton, MD, a pediatric surgeon, the next morning at the pediatric trauma quality improvement meeting. After speaking with him, I decided that he would do the implant for Patricia; I was pleased. Great plan. When he recommended general anesthesia, however, I balked. This is a Supprellin implant. I thought that we could easily do this in a procedure room with local anesthesia. I have taken these out, and they are tiny little things; I could not imagine why general anesthesia would be necessary — I did not even want sedation for Patricia. Dr. Kayton hesitated, and he definitely felt uncomfortable with my request. Thankfully, he acquiesced, and the procedure went well. However, the day before surgery, two different people called our home and gave two different times for the procedure: One reported the procedure was 9 a.m. and the other at 11 a.m. I called the OR the night before surgery and found it was on schedule at 10 a.m.
The charge for the Supprellin implant was $25,000. Who would have guessed?! Not I. First, the insurance company called and explained that our responsibility would be about $15,000, and it would cover $10,000. Then they referred us to another organization that helps supplement coverage for the implant. I was wondering how my patients with Medicaid were able to afford this medication. I called and asked one of my patient’s mothers, with whom I am friendly, and I also asked our hospital pharmacist. I found out that Medicaid does not have to pay what we have to pay, and Medicaid patients do not have to cover the same deductible or out-of-pocket expenses. The patients with insurance cover those with Medicaid. I was confused by the multiple facility charges and professional charges, but I understood how they are generated. I was grateful for the heads up from Aetna. I can imagine how confusing this process would be for a layperson.
Takeaways from the Experience
I think that having a patient financial liaison would be helpful, someone who would be able to help the patients and their families navigate through the complex charges, EOBs and payments. It would be useful to explain to patients and their families that denials of coverage and payment are common. Most parents have no medical background and most have never actually read their health insurance policies. Many of our patients don’t know what a deductible is, and they certainly do not know the amount of their deductible. “Co-pays” and now “co-insurance” are also unfamiliar terms for parents.
In my opinion, Obamacare has not helped simplify health insurance or medical billing and collections. It has instead increased the complexity of health-care delivery. Parents feel paralyzed, confused and angry about the denials, partial payments without real explanation, and lack of clarity from their respective health insurers. As neurosurgeons, there is really only so much that we can do. I know that my office has done more advocacy and education for patients than ever before, and they still need more help. Hopefully, things will improve for patients and physicians alike. But there will not be improvement in these processes and systems until we as physicians stand up for our rights and the rights of our patients.
[aans_authors]
