I have yet to receive a response to this letter, and the patient still has not been reimbursed by his insurance issuer (7 months after the surgery); therefore, I am presently redacting the company name. It is one of the big remaining few companies, to whom I have written before. Patients and physicians are acting in good faith. Insurance companies cuddling in bed with big government are preying on our calling and goodwill, as they laugh all the way to the bank operating per a business model that combines the ineptness of the Three Stooges and moral code of a sponge.
March 1, 2017
Dear Secretary Price and Mr. _________,
With continued dismay, I seek your attention to resolve a serious matter where government healthcare law and commercial insurance company practice collide once again to harm my patient. Ironically, we have come to the point where the patient, for whom healthcare laws and insurance companies were created, is now the last one helped and first one hurt, as if an annoying afterthought in a convoluted web of third party misplaced priority and moral inversion.
My patient is a 71 year old gentleman who suffered from decreased vision due to cataracts in both eyes. He has had 5 cardiac stents placed and is on blood thinners. I successfully performed laser cataract surgery with placement of a toric intraocular lens in each of his eyes (08/18/2016 and 08/25/2016), and thankfully he now sees 20/20 in each eye without glasses. His suffering has been alleviated, his quality of life improved, and his ability to perform his activities of daily living with continued independence markedly enhanced. Sadly, your health insurance company refuses to cover the cost of my surgical fee in what could potentially be construed as a pattern of misrepresentation and errant billing.
The patient pays for coverage under the _____ Teacher Retirement System of Texas. I am an out of network provider for TRS, and my status with Medicare is classified as “private contracted” or “opted out.” In other words, my agreement is directly with my patient, and I have no agreement with _____. In fact, neither the patient nor I can submit a claim directly to Medicare or a supplement plan. ____, on the other hand, as a commercial replacement plan, has an agreement with my patient who pays monthly premiums for promised coverage. _____ TRS serves as a Medicare replacement plan and has an agreement with CMS for which it accepts federal funds to pay for services for Medicare patients. While I have honored my agreement with my patient, _____ has not upheld its agreement with its client or the federal government; in other words, _____ is breaching its contract with its client and the federal government. _____’s stated negotiated amount of coverage for the surgeon fee for cataract surgery is $618.81. _____ refuses to reimburse their client (my patient) for this amount for each eye. Initially, _____, made a mistake and processed the claim as if I was an “in network” surgeon. Subsequently, (after the patient has already had the operation and come out of pocket) _____ is refusing to reimburse the patient. _____’s own Benefit Detail states 100% coverage for “in network” and “out of network” specialists. The patient opted for _____ as a replacement plan in lieu of traditional Medicare but is now denied reimbursement for services received from an “out of network” provider. One must ask: What has the patient been paying his monthly premiums for, and what has _____ been doing with the money it receives from the federal government?
Neither commercial insurers nor Medicare covers laser use during cataract surgery or toric intraocular lenses. Intraoperative use of such advanced technology is an instance where balance billing is the correct, legal standard of practice and billing. Had my patient gone to a “participating” Medicare surgeon, the overall fees would have been dramatically higher. As a third party free surgeon, my fees are transparent and significantly lower, saving the patient and the healthcare system at large a substantial amount of money. The patient should be commended for using such a practice- not denied coverage. _____ must reimburse the patient the negotiated $618.81 per its negotiated rate for each eye for a total of $1237.62 plus the cost of the initial examination and preoperative consultation and measurements ($135.00, $103.42, $79.54 totaling $317.96) for an overall reimbursement due of $1555.58.
The time and resources required by the physician and her staff to help the patient fight for his due from _____ is enormous and usurious. _____ willingly takes money from the patient and federal government but then fails to fulfill its agreements to pay negotiated rates to those whose services they advertise to sell. Such patterns of errant billing and denial of payment suggest either an overall ineptness (further encumbering a flailing healthcare system with 3rd party waste of resources) or a dubious underlying business plan that seeks to profit from an intentionally convoluted, prolonged, and cumbersome process of prior authorization and denial of claims. This could be perceived as a violation of the false claims act, breach of contract, as well as flagrant theft.
I look forward to resolving this issue expediently. The patient must come first. I look forward to positive solutions and clarification under Secretary Price. I await your timely response and reimbursement of your client.
Kristin S. Held, M.D.