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Insurance Issues
The Insurance Dilemma

Many health insurance companies do a poor job of explaining their many different and confusing policies. Nevertheless, it is your insurance company’s responsibility to explain these policies to you.

Sometimes when we ask a patient to make a co-payment, they ask us to call their insurance company to find out how much that payment is.

When asked about deductible amount owed, patients will sometimes ask us to find out for them.

Please remember your health insurance policy belongs to you. It is your responsibility to know about your policy and you have been provided a number to call about payment, co-payments, deductibles, what services are covered, which providers you are allowed to see and which facilities they will cover.

We will not call your health insurance company for you. Please do not ask us about your insurance company policies. It is not our job to clarify them for you. Our job is to render the best possible medical service for you as a patient. If you have such questions about your policy you need to call your insurance company directly.

Many health policies are the PPO type. A typical PPO plan has a high deductible. Typically the deductible is about $1,500-2,000. All medical services are your responsibility until your deductible for the year is met. Once you have met your deductible, a typical plan pays about 80% of the bill. You are still responsible for the remaining portion of the bill, which may be 20% or so. This is the point at which many patients are confused. Since they have already paid their insurance premiums, some patients believe their PPO covers 100% of their medical bill. This is not the case if you have a PPO policy.

If you have not met your deductible, you are responsible for our entire bill. If surgery or colonoscopy was done, you will also be responsible for a portion of the hospital bill. Most of the time, the hospital billing company does its billing immediately. If you have not met your deductible you will have to pay the hospital quite a bit of money.

The problem is that our doctor also has to be paid for the service he rendered for you. Our office bill, which is separate from the hospital, may arrive later. Many patients then get upset at our office. They complain that they have already paid a lot of money to the hospital. Some patients tell our office they do not want to pay our bill. These patients do not understand that their health insurance contract makes them responsible for this bill – they cannot just walk away or ignore the doctor’s bill. That would be the same as breaking the contract they signed with their health insurance company.

We live in hard financial times. Although it is beautiful in Northern California, it is very expensive to live here. Taxes, fees, housing, food and living costs are higher here than anywhere else in the country. This is also true for the local doctors and specialists. Not only do they see the higher costs of living in Northern California, they also see that costs of doing business here are very high. For example, when our office was in Colorado we could provide Workers Compensation insurance for over 5 employees for under $1,000. In Northern California with ˝ that many employees, our Workers Compensation insurance is in the 1,000s of dollars. Rent, utilities, wages and other business costs are much higher here. To add insult to injury most of the insurance companies, Medicare and Medi-Cal pay much less for physician services these days. Some insurance companies offer less than the Medicare rate. People living here do not know that they will soon face a major crisis in health care as more and more doctors leave for areas like Idaho, Texas or back east where the costs of business are less and reimbursement is higher.

Many companies that provide health insurance for their employees are shifting more of the burden and costs to the employees. The day of employer health plans that cover everything has long passed. An example is Whole Foods Market Inc. The 159-store grocery chain last year adopted a plan that makes its 30,000 workers feel a bit of pain every time a health service is rendered. The company hopes this will slow down growth of medical costs and share costs with its employees.

Health-maintenance organization (HMO) plans have lower premiums and no deductibles. The employee pays a co-pay each time they visit a doctor, but they are limited by selection of doctors. The disadvantage is that some specialists may not be part of an HMO panel, so those patients have to pay to see out-of-plan doctors.

Here are some questions from patients:
I do not want to give your office my social security number - I am concerned about identity theft.
Our office respects your concern about identity theft. Often your social security number is tied to your insurance policy. If you cannot give us your social security number, we expect you to pay your bill in full - we will then give you the billing information for you to submit to your insurance company.

I do not want to call my insurance company – you need to call them for me or I will not come to see Dr. Khoo.
Please understand that there is no way our office staff can know every nuance and rule of your insurance company. As a consumer you made the choice of your particular insurance company – as a responsible consumer you need to make the effort to understand your policy and its rules. When patients have told us they would go elsewhere unless we called their insurance company, we have sadly told them that they were free to do so – it is not our job to explain your insurance policy to you. We feel that we would be a less effective medical office if we spent fruitless hours on the phone with different companies trying to understand their rules. We want to spend as much time as possible delivering excellent patient care.

I pay my insurance premiums monthly – why did your office send me a bill?
Usually the bill is the balance that your insurance company did not pay – you may not have met your deductible or even if you had, you may be responsible for a co-insurance portion. These are not arbitrary numbers but figures that you agreed to when you signed on with your health insurance company. Please call your company or insurance agent to explain this to you.

Why does your office use the E-Z Pay system and why do I need to provide a credit card?
After many years of practice in the U.S., Dr. Khoo found it frustrating that too many times his consultations and surgeries were not being paid in full. In some cases he received no payment at all for the work he did.

E-Z Pay allows our office to collect fees that are a patient’s responsibility without having to waste time and money sending out bills and reminders. Using E-Z Pay allows us to focus on patient care instead of bill collection. Dr. Khoo has set a reasonable fee based on the government set Medicare fee schedule. The fee structure just allows for him to cover his expenses and salary needs. Unlike some hospital systems that bill patients exorbitant fees, he does not do this.

For years Dr. Khoo and his staff would spend hours and hours dealing with insurance companies, the government and patients trying to get paid for services that he rendered months and sometimes years ago. Best Buy and Albertson’s would soon be out of business if they were not paid immediately for their products. At these stores and many others if payment is not immediate, it is secured on a credit card. When you check into a hotel, you have to give the front desk your credit card so it can request a hold on your card. The hold is essentially a reservation on funds available through your credit card to ensure you don't exceed your credit line when you check out. This is the same reason why we request a credit card when you come to our office.

Inc. Magazine said it best in the December 2003 issue calling Medicine “The Worst Business in America.” The issue stated, “Suppose you couldn't raise prices, you couldn't control expenses, and you were morally obligated to meet the needs of customers who are eager to sue if anything goes wrong” as an introduction to the business of medicine. The article questions why anyone would participate in such a business.

Our office needs to guarantee that Dr. Khoo is going to be paid, so you do need to provide a credit card. This policy and our payment system is explained before patients arrive for their appointment. We don’t like to surprise patients.

In-Network or Out-of-Network - a recent problem encounter

Recently a patient with Pacificare HMO called for an appointment. We accept Pacificare HMO and PPO, but we did not realize that the patient was enrolled in a special Pacificare plan with the Sutter Medical Group of the Redwoods - we are not contracted with this sub-plan. The patient wasted a long time to discover this fact.

Patients have to be very careful and do their research about their health plan. As I always stress, you get what you pay for. If you have a cost-effective (inexpensive) plan, it isn't necessarily because the plan is efficient. You are saving money because that plan bullied their panel of doctors into accepting lower than customary reimbursement. Your 'cheap' plan may not allow you access to all specialists and you may not discover this fact until you have a complex health problem. Your 'cheap' health plan banks on the fact that most of their members will not need a sub-specialist. Be your own advocate and call your plan to demand coverage for certain specialties.

My office often gets calls from frustrated Kaiser patients, because the closest Kaiser colon surgeon is 60 miles away in San Francisco or Oakland. Kaiser has very few colorectal surgeons and there is a several month waiting list. When patients have a serious problem like cancer, they get frantic. When I arrived here in 2002 I offered to see Kaiser patients but was rebuffed. I understand Kaiser's position - since the organization needs to save money, they have to ration care to their members. Kaiser is fine if you are healthy and really don't need to see a sub-specialist. You get what you pay for.

Copyright © 2009 Center for Colon and Rectal Surgery, 864 Second Street, Santa Rosa, California 95404 U.S.A. All rights reserved.