Health Insurance & Patient Responsibility, Part II

By Deborah Cho

In my first post, I introduced the general problem of patients not being fully informed about their health insurance policies and instead relying on providers to correctly apply each patient’s unique policy when making medical decisions.  Though patients are ultimately responsible for abiding by the terms of their individual insurance plans, there may be ways that health care providers can help patients avoid being stuck with unnecessary and unmanageable medical bills.

One solution might be to make giving a general statement about the importance of understanding how your health insurance policy relates to recommended care become standard practice during patient encounters for physicians and other health care providers.  Health care providers can, for example, add something along the lines of “You may wish to check with your insurance plan to see if this is covered” when providing a recommendation for treatment or when providing a referral.  Such practice should not place liability on health care providers to guarantee that patients have an accurate understanding of their insurance coverage.  Instead, insurance coverage and medical debt should be viewed as factors that can directly affect a patient’s health and well-being, thus deserving a few moments of the patient encounter whenever possible (perhaps similar to brief counseling on smoking cessation, which is covered only if appropriate and timely).

A potential issue with this is that it may discourage patients from seeking the recommended care on the assumption that it is not covered because the provider has made such a statement.  To counter this, providers can keep this in mind and be selective about when and how they offer this advice.

For example, these statements can be given exclusively with referrals, as patients have the viable alternative of seeking referral to another provider, if the issue is in-network versus out-of-network, or to another type of specialist who offers comparable care.  Alternatively, these statements can be given exclusively with recommendations for non-urgent and non-medically necessary care, so patients can make an informed decision about whether receiving this care is worth the cost.  (Since medically necessary care is generally covered by insurance, the potential harm in deterring patients from receiving medically necessary treatment may be greater than the benefits of informing the patient of potential financial ramifications of receiving that care.)

Another option is to highlight this issue only when recommending further care that is particularly costly, where the risk of crippling medical debt is the highest. Though this will undoubtedly necessitate value judgments in deciding what is “costly,” both in terms of what care is worth and what constitutes a financial burden, this could be adjusted according to the patient or population.  Lastly, a staff member other than the direct health care provider could give this brief reminder to the patient when handing over a referral slip or directions to a lab or diagnostic center.  This may alert patients that this advice is not tied directly to the specific service ordered for that particular patient, but is a general notice about how medical care is billed.

As in the practice of medical care, providers should be given much discretion over when and how to offer these words on health insurance.  The most important change that should be made is that providers need to be aware that this could be an issue for patients.  It only takes one misunderstanding for a patient to take a provider’s off-the-cuff remark about a certain hospital being “the best at treating such and such” to believe that that hospital will then be covered by his insurance, only to be left with tens of thousands of dollars in medical bills when that hospital is in fact out-of-network.  If providers are aware of this possibility, they can then apply their best judgment on how to empower their patients to make informed decisions regarding their medical care.

Though this proposal is not by any means a perfect solution, it is one potential means of assuring that health insurance coverage is as meaningful and effective as possible.

[See Part I here.]

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.