Cards Perplex Doctors, Patients
Published 29th March 2006, 12:25pm
By Iris Stoner
Some doctors are still refusing to accept valid insurance cards from patients without first attempting to verify coverage.
Mervyn Conolly, superintendent of health insurance, understands the concerns of doctors.
“I recognise that health care providers have legitimate issues that have to be addressed. We don’t want them exposed to risks of not getting paid for services provided. They have reasonable concerns.
“Health care providers cannot with confidence be 100 per cent sure that insurance companies will pay for services provided.
“Sometimes the patient is not covered for the particular benefit and it is not that the health care provider would not take the card. It is not always the health care provider at fault,” he said.
Mr. Conolly explained that the doctors have to do their part, however.
“We want the health care providers at least to try to verify what benefits are covered.
“We’re saying that in instances where you have a valid insurance card with a level of benefit that would cover the services and procedures required by the patient, the health care provider should make reasonable efforts to verify the coverage.
“The commission also wants to be able to follow up on complaints from health care providers if they are not getting claims paid on time,” he said.
As recently as late last year, a forum which included Mr. Conolly; Minister for Health and Human Services Anthony Eden, representatives of insurance companies and doctors, addressed compliance with the 2004 Health Insurance Regulations.
Ear, nose and throat surgeon Dr. Robert Glatz finds there are still problems with the verification process.
“The law is misleading. Doctors will accept the insurance card when they know the insurance company will pay, but they will not guarantee payment. No insurance company will.
"They'll tell you the insurance is intact and it is up to date, but they won't tell you they will pay for a specific situation," he said.
The doctor has to look at each case individually.
“I accept the card as a courtesy for large amounts such as for surgery; most physicians will do that. But for office visits, there are so many instances where the insurance company doesn’t pay.
“For office visits, I will ask for payment up front and I’ll fill out the claim form for the patient and I’ll have them drop it in the mail,” Mr. Glatz explained.
Mr. Conolly understands there are situations that prevent doctors from being able to accept a person’s insurance.
“If a doctor takes the insurance card and can‘t get through to the insurance company, it’s not his fault. At least, in those instances, a doctor could fill out the claim form for the patient,” he said.
If a doctor refuses to take an insurance card and will not try to verify a person’s coverage, then the patient may file a complaint with the Health Insurance Commission, Mr. Conolly, who is also CEO of the HIC, explained.
The HIC will investigate the complaint and take any appropriate action, he said, but added that the complainant should be willing to go on the record.
While there is no fine for refusing to take an insurance card, there are penalties for not cooperating with a health insurance investigator.
If a doctor will not answer questions or obstructs the investigation he can be liable on summary conviction to a fine of $5,000.
“We are hoping the health care provider will be professional enough or ethical enough to work with us on a particular issue,” he said.