Health insurance standards confuse

Not all patients and doctors truly understand the Government’s standardisation of health insurance fees.

On Friday, in a continuing effort to clarify and standardise the claims and reimbursement procedure, the nearly 10,000 health insurance fees were gazetted.

Mervyn Conolly, Superintendent of Health Insurance, explained the importance of the year-old law.

‘The Health Insurance Amendment Law, 2004, states that health-care providers should first seek debt payment from the insurance company,’ Mr. Conolly said.

In layman’s terms, this means that doctors are legally required to try to file claims on behalf of their patients and receive their payment from the insurance company.

If the patient does not have valid insurance, he or she must pay the bill up front.

If the insurance company does not cover the entire claim, then the doctor must seek payment directly from the patient.

Mr. Conolly acknowledges the process involves some amount of administrative work on the part of doctors, but views it as part of the greater good. The publication of the almost 10,000 fees will smooth the process, he added.

These standard fees, which will be implemented 1 August and will be reviewed annually, will specify the amounts approved insurers will reimburse health-care providers for services to an insured person.

The amount above these published fees may have to be paid by the patient to the doctor. Patients will also need to pay any co-payments and/or deductibles when they are treated.

To start the claims procedure, the doctor’s office needs to contact the patient’s health insurance company to confirm coverage details and get the visit pre-authorised.

Not all practitioners are happy with these requirements. Optometrist Dr. Elaine Campbell sees several faults in the claims process.

‘I have a philosophical problem with this system. Why is the doctor involved at all?’ Ms Campbell said.

A problem specific to optical providers is that patients are limited to anywhere from one claim per year up to every two years plus one day.

‘If we haven’t been able to get pre-authorisation, and I send in my claim form for a patient, I won’t get paid if they are under the time limit. By the time we know that, the patients have their glasses. We can’t stop them in the street and take them off,’ she said.

Ms Campbell compared the situation to homeowners dealing with insurance companies.

‘Why aren’t loads of lumber being delivered to people’s houses and then they have the insurance company pay later?

‘When I question the system, I’m told that this is how it’s done in the States, and that’s really not a good enough answer in my opinion,’ she said.

The requirement to receive pre-approval from insurance companies poses another difficulty for Ms Campbell.

‘More time is spent getting pre-approval. My staff isn’t doing what they were hired to do,’ she said.

Ms Campbell is also concerned about the potential for misuse of the system.

‘Everybody gets to contribute to abuse of the system. Patients may overuse it, doctors order more tests, and the insurance companies say they approve the eligibility of the patient, but then they don’t pay or won’t pay the full fee. They may claim it’s a pre-existing condition,’ she said.

Mr. Conolly sees the issue as getting all the involved parties to work together to improve the system.

‘We believe all stakeholders will have to contribute toward the smooth operation of health-care provision: health-care providers, insurance companies, government, employers and employees/patients,’ he said.

The publication of the fees, which took three months to compile, involving a survey, research and analysis, will make the process that much clearer, Mr. Conolly explained.

‘The publishing of the fees brings everything to light, it’s transparent.

‘Insurance companies will use these fees to reimburse health-care providers. And insured people can now find out what services and procedures will cost.

‘If you have educated consumers, at the end of the day, that’s a good thing,’ he said.

Once the fees and all the insurance procedures are understood, the system will work that much better, he explained.

‘The more information we get out and the public understands how it is supposed to work, there will be more cooperation and compliance.

‘This is about trying to achieve some semblance of fairness across the board,’ Mr. Conolly said.

Any accusation of non-compliance with the health insurance law will be investigated, according to Mr. Conolly, and violators may be subject to a minimum CI$5,000 fine.

Ron Sulisz, CEO of Cayman Islands National Insurance Company, sees the publication of standard fees as a benefit.

‘It makes it easier. If I’m a provider, I know what the insurance company will pay,’ he said.

Referring to last year’s amendment, Mr. Sulisz added that the doctor will also need to know if the patient is covered and has to verify the insurance details.

“No one likes change, but you have to consider if it is going to benefit society,” he added.

Sheila Richmond-Peck, medical assistant for obstetrician/gynaecologist Dr. Greg Richmond-Peck, has encountered problems with the claims procedure.

She cited the time required to receive pre-authorisation as well as long waits for reimbursement through some insurance companies.

‘The doctor is here to practice medicine, not practice accounting. He is not a banker, not an accountant, not an insurance adjuster,’ Mrs. Richmond-Peck said.

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