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The Relationship between your doctor and your insurance company

This article is about insurance companies and how decisions are made concerning their subscribers.  It must be stated in the beginning that there are many fine insurance companies and doctors who make proper decisions concerning the health of their subscribers.  This article is not about those who make such proper decisions.  The decision making process that insurance companies have in place need to be examined to avoid issues identified in this article.

Recently there have been cases where insurance companies have denied payment for procedures which resulted in the death of a covered subscriber.  This kind of decision making process needs to be reviewed by all insurance companies.  The cost of insurance is high in many cases and insurance companies have a responsibility to keep costs down.  However when a decision is made to reject a claim which results in the death of a covered subscriber it raises many questions.  I agree that there are cases where insurance fraud may exist but patients and their health should not be put in the middle.  There are many fine doctors who have the best interest of their patients in mind.  When insurance companies override decisions made by doctors it creates a dangerous situation.  In some cases rejecting a doctor’s diagnosis or not processing a claim expeditiously can cause death or a deteriorating health situation.  If the decisions by insurance companies involve doctors I find it to be a problem that a doctor would make a decision on a patient they have never examined.

I personally would never want a doctor that does not know me or my medical history to make a decision on what medical procedures I need.  Insurance companies have a variety of plans and it is right if they reject procedures that are not covered by a patient’s plan.  Some insurance plans have gray areas for some services and it makes it difficult not only for an insurance company but also for patients to know what is covered and what is not.  Insurance plans should be clear in what they cover and how much so there are no mistakes made for decisions affecting a patient’s health.

I agree there are those who will commit insurance fraud but these events when they are discovered should be prosecuted to the full extent of the law.  Putting patients and their health at risk is a practice which needs to be refined.  Again I agree that insurance companies must process claims according to a patient’s plan but sometimes the language can be interpreted differently.  In these cases insurance companies should error on the side of the patient rather than make a decision that is later overturned based on a public outrage for their rejection.

Individuals should not be penalized for those doctors who abuse the system of charging for services and medications that are not needed.  Doctors should be held accountable for their actions and their patients should not be penalized for care they need.

I have seen or heard of many instances that patients had to be released from hospitals since insurance companies have set rules in place for charges.  These rules can be a good thing in keeping insurance costs low.  However, these rules can have a detrimental affect upon patients.  Patients should not be forced to leave facilities where it is felt by their doctors they need to be.  While this may increase some cost to insurance companies it is why we and our families have insurance.  Insurance companies must be careful about rejecting procedures that could affect the health of their subscribers.  There are cases where hospitals and doctors are informed of limitations for hospital stays and a patient is released only to return causing additional costs.  The additional costs in many cases, I believe are larger than if the patient had originally stayed until their health improved enough to be released.

Many people today have needlessly been sent home from hospitals as a result of insurance companies making decisions about how long you can stay.  While this situation may be one of necessity in some cases to prevent what they feel are unnecessary expenses it is not acceptable.  Doctors caring for patients who are sick and in the hospital must have the authority to make the decisions regarding the health of their patients without insurance companies setting defined rules for length of stay and medications.

Insurance companies are a necessity and many people need them to help with their medical bills should they have any.  Insurance companies are a business just like any other and they must control cost and watch for fraud with their customers.  Insurance companies must pay in accordance with the policies in place when an insured has a medical problem.  Before paying a claim it must be validated that the service has been given.  This is a key ingredient in paying the bill.  Doctors and other medical service companies must have accurate records and submit bills due for payment from the insurance company before asking for payment from patients.

In summary doctors and insurance companies must work together for their patients and clients benefit.  Doctors should be aware of the need to control cost and only prescribe what a patient needs. As indicated in the above paragraphs the working relationship between your doctor and your insurance company in many cases leaves a lot to be desired.  Many doctors have developed a relationship with insurance companies and in many cases this helps in the processing of claims.  Those doctors who develop such a relationship and have proven themselves should not have insurance companies override their decisions.  Insurance companies should put the health of their subscribers first and in many cases decisions made give the perception that they only care about the cost not the health of their subscribers.  This is a perception insurance companies do not want to have.









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Dennis AuBuchon

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