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.
Trevor Stewart, senior vice president of health insurance for Cayman General Insurance, explained why the issue of verification is not clear cut.
When insurance companies get calls from doctors about a patient’s coverage, the only thing that can be verified is that he or she has valid insurance, he said.
‘But doctors don’t know what the diagnosis is going to be, so if the condition is excluded, they won’t be paid,’ Mr. Stewart added.
Another complication is that if the doctor waits until after the consultation to check on the insurance, he may then discover that the patient isn’t covered.
In addition, Mr. Stewart explained, if the person’s diagnosis is related to a pre-existing condition of which the doctor seeing him is not aware, the patient won’t be covered.
Other problems come from the doctors themselves, he added.
‘Many times when we ask for clarification from doctors, that is not forthcoming,’ Mr. Stewart said.
The use of the government’s standard health insurance contract is also an issue.
‘Under the SHIC, the outpatient coverage is $100 per year and that runs out quickly. You can’t blame the doctors for collecting up front because they don’t know if that money has been utilised. The claim can be in the mail, for example, and the insurance company will not know this so will not know the coverage is utilised,’ he explained.
Mr. Conolly says there is a solution to that and related problems.
‘The way for us to really look at verifying the health insurance benefits a patient has is to look at an electronic verifying system to address it,’ he said.
This would involve swiping the insurance card and receiving online verification much like checking a credit card, he explained.
While all these issues are being addressed, the HIC continues to field complaints.
There were 47 complaints to the Complaints to the commission in January and 42 in February. Complaints against employers comprised the largest category, posting 23 for January and 20 for February,
Most of those complaints involve employers not taking out insurance for their employees.
In general, complaints to the commission average 27 to 28 a month, he said, but he believes the higher numbers for this year are related to increased public awareness.
There have been television and radio ads as well as public forums about insurance.
‘So more people could be approaching the Health Insurance Commission about their concerns,’ he said.
Mr. Conolly is trying to find the best way to make the insurance system work.
‘At the end of the day, what we want to do is have the best-functioning health care system and health insurance system we can have.
‘Insurance should spread cost and risk to make health care affordable and accessible to all of our citizens. We don’t want to encourage waste and encourage abuse.
‘The bottom line is we should not expect health care providers to provide services and not get paid for the services they provide,’ he said.