A Doctor's Lament on Health Insurance

Health insurance is really beneficial for both the providers and their patients. Patients receive benefits by being able to go to a provider (a doctor, a hospital or an independent medical facility) and save money by paying only a small fraction of the bill or even receive services for free. As for providers, since patients would usually prefer to use their insurance cards, they will have more patients.

I worked for a health insurance company before and we were handling provider calls for their claims and verification of benefits for their patients. It really isn't that easy for providers to get paid for the services they have rendered to a member patient. They have to verify themselves if the patient still has active insurance. Most providers would require a letter of authorization from the insurance company before rendering any service especially for HMOs.

But for patients who have a wider coverage like a PPO or private fee for service, providers usually call the insurance company themselves. Then, after rendering service to a member patient, they have to file a claim in order to get paid. If you're asking how long it takes for a claim to be processed, based from the different health insurance companies I've had and worked with, the usual turnaround time is 30 days.

Recently, we've been to a doctor (who I shall not name or give a clue about for security purposes since there may be court cases related to this) to have a diagnostic check up. That doctor still remembered us even though we last came to the doctor's office 4 years ago. We had a few small talks since there were no patients on queue at that time.

Before I had health insurance from my employer, I was a private patient of that doctor. It was way back in 2004. Now that I have health insurance, I asked what insurance company the doctor is participating with. To our surprise, the doctor isn't participating with any insurance and only accepts private patients. We were astounded when the doctor told us the reason why.

The doctor pointed towards a huge cabinet and showed us a pile of papers. All of those papers were unpaid insurance claims. The doctor told us that it's actually worth hundreds of thousands of pesos or it may even have reached a million pesos or so. I stood up and the claim forms were as high as my pelvis. Unfortunately, the health insurance company closed probably due to bankruptcy and our doctor told us that it's been more than a year now and the claims still aren't paid.

Well, I can really understand how our doctor felt about medical insurance. Our doctor said, with conviction, "I won't be participating with any health insurance company anymore." To be fair, there are really good insurance companies out there. They process claims on time and do pay per contract. But sometimes, we may be unlucky to be working with a bad insurance company. Ask around for feedback about your health insurance regarding how they treat members and providers. This way, you'll have an idea how trustworthy your medical insurance is.