– by Louis B. Cady, M.D., Founder, CEO
If you are reading this brochure on the Internet, it means that you either are or possibly will soon be a patient at Cady Wellness Institute, or have simply landed on this page to check things out!
Because it is my staff’s and my desire to provide the best medical care, and because part of any successful relationship with a medical or mental health care professional is trust and good communication, I written this overview guide for you reflecting my experiences with billing and insurance companies. This brochure should also help to clarify the nature of your relationship with me or with any health care or mental health practitioner here at CWI, our responsibilities to you, and your responsibilities to us in our collaboration with you in you medical or mental health care.
In past times, the relationship of trust and mutual respect has been inherent in the patient – doctor and patient – therapist relationship, and that is the way I want our relationship to be. In addition to the professional nature of our relationship, however, there is a business relationship which consists of our willingness to provide a service to you and your agreement that you will be financially responsible for that service. In the “good old days,” the nature of this relationship would be much clearer than it is today, because previously medical care or psychiatric care was relatively simple and people could pay for virtually any normal amount of care that they needed out of their pocket. However, with the advent of complicated and high priced technology, insurance companies appeared on the scene. While the development of insurance has been a wonderful blessing to many people who have catastrophically high health care costs, it introduces an extra “layer” between the unwary patient and the unwary physician. Many patients, these days, feel that it is “the insurance company’s job” to pay the medical bill and that their only responsibility is to pay the premium or work at a job where their insurance is provided for them. In the best of all possible worlds, this would be a perfectly reasonable proposition, and the insurance companies would pay exactly what the physicians or other care providers charged. However, this is no longer the way insurance companies and the HMO industries are working in our country today.
“THE HEALTH CARE CRISIS”
Unfortunately, we are living in an era where many people are uninsured. As we enter the political season in 2008, the topic of access to health care is being much discussed. Other than lack of insurance, and, in many cases, lack of ability to pay, the main “crisis” is not really a shortage of physicians or lack of government spending on health care: no government spends more! The real problems are multiple and complex:
1. New and deadly diseases.
2. The high cost of new technology to treat diseases that were once fatal.
3. The irresponsibility of a portion of the public that believes that someone else should pay their medical bills and, as a result, do not assume responsibility for their own health and well-being.
4. The tragic confluence of aggressive marketing by food companies, increased sugar and increased caffeine in addicting, bad-for-you foods, and the complicity of the “medical –industrial complex.” In essence, the junk food providers and fast food joints and the mega-pharma companies have an unholy bargain: “You fatten’em up, get’em diabetic, hypertensive, and get their cholesterol levels high, and we’ll sell’em drugs to treat these conditions.” Since somebody else ends up footing the bill – the US taxpayer if the costs are paid out of public funds, or some clean-living healthy person in your insurance pool of risk that is paying in more in premiums than he/she takes out in benefits – the irresponsible people “win” and you get stuck with higher insurance premiums.
As a result of the inceased “pay-outs” of the insurance companies to treat the not unsurprising explosion in need and costs brought on by an increasingly obese, sick, diabetic, and unhealthy population, insurance companies have begun trying to chisel away at their expenses wherever they can. Unfortunately, this is likely to affect your reimbursement for medical and/or psychiatric medical charges for which you will be responsible here at CWI.
“THE USUAL AND CUSTOMARY FEE” POLICY
To be blunt, many insurance companies have taken to price fixing in order to hold down their costs. While they would never say that in their policies, it is accomplished as follows: when you exercise your right to choose a physician, therapist, or provider under your health insurance policy, you essentially trust the insurance company to pay what your provider charges – or at least a reasonable approximation thereof. However, the actual treatment contract is not between the insurance company and the physician/provider but between you and me, or you and one of our staff here at CWI.
When you make an appointment to come to CWI for professional services, you are essentially contracting that you will pay us for them. Naturally, you expect to get reimbursed at least a reasonable amount from your insurance company. In practice, this frequently does not happen. You may submit a claim to the insurance company and have it returned to you with only a partial payment for our services, stating that our fees exceed the “usual and customary” levels. It should be noted that this does not mean that our fees are exorbitantly high, unreasonable, or unconscionable. I feel that our services are fairly priced for the value that they represent. Insurance denial of the full fee only represents the fact that they are trying to “nickel and dime” all of their policyholders to recoup some of their costs which they are losing in the treatment of exceptionally costly diseases and chronic conditions for other patients. Unfortunately, this does not help you. Generally, you will not receive reimbursement for the full amount which you have paid us back from your insurance company, and, if you have a high deductible policy or are still in the early part of the year when you are paying up to your deductible limit, you may not receive anything back.
Other tactics that I personally have encountered from insurance companies include delaying payments of claims to patients for five to six months or deliberately miscoding the diagnosis which our staff scrupulously encodes on invoices, or reimbursing you for a less expensive service than what was actually performed. Many insurance companies are quite honest and reputable and do not do this sort of thing; I can only report that it has been my unfortunate experience to witness this sort of behavior by several insurance companies the policies of which my patients carry.
Please note that your coming up against the “usual and customary fee” limitations is not just likely to happen with our services, but virtually with any psychiatrist or other physician with whom you may contract to provide care. Unfortunately, many insurance companies are trying to “squeeze” patients and physicians in the mental health care area.
Interestingly, I have seen the “usual and customary fees” for my psychiatry fee codes lowered in the last several years by insurance companies. How interesting! My malpractice insurance payments haven’t been lowered, nor my light bills, nor my staff’s salaries, nor my grocery bills. But insurance reimbursements have been. One wonders why.
The answer, obviously, is that insurance companies are engaging in price fixing and deliberately cutting back on fees they will pay for service. “Cost savings” may be one of the reasons they allege; incontrovertibly, however, they are effectively forcing the people who trusted them to insure their very lives and mental health to get cheaper and cheaper care – or not to get it at all because no physicians or “providers” will take the increasingly small payments. Please don’t call our office and tell the staff, “Dr. Cady (or one of my clinical colleagues here at CWI) is cheating me; my insurance company says that he is ‘charging too much.'” Not so! They are paying too little!
If I were you, I’d complain to them, to my company, and to whoever selected my insurance for me. If you have any choices in the matter, I’d change insurance companies if you can. Increasingly, patients – or “mental health consumers” as they are bureaucratically called by the insurance companies – are voting with their feet and leaving crummy plans. Interestingly enough, Minneapolis, Minnesota – a short distance from where I did my residency training and the original hotbed of the HMO movement – has had a massive reorganization of the local insurance and “managed care” organizations because companies were hearing such complaints from their employees!
PAYMENT AT TIME SERVICE IS RENDERED
Because the contract to provide service is between you and me, and the contract to provide insurance is between you and the insurance company, the policy at Cady Wellness Institute is that I request payment at the time the service is rendered. This may mean that after you pay me the full amount for my services, the insurance company will not fully reimburse you. However, it has been my experience that an irate policyholder calling an insurance company and demanding a settlement of a claim is far more likely to produce results than a physician’s office calling the insurance companies and asking for a reconsideration of an insurance payment for a service rendered. As such, this puts the responsibility squarely on you in order to have the insurance company contractually meet its obligations to you. Furthermore, you have legal recourse to actually sue the insurance company if it does not abide by the insurance contract between you and the company. Usually, the mere threat of legal action by an angry policy-holder speeds up their processing of claims in near-miraculous ways!
FULL DISCLOSURE UP FRONT
If you are considering our providing you with services, you have every right to know, up front, completely in advance, what my charges will be. It is the American Medical Association’s policy that fee information should be immediately available to patients at their request; it is also my policy. There may be some minor imprecision in your being advised of exactly what your service with me will cost. This is because with exceptionally complex cases, I may run the appointment 15 to 30 minutes longer in order to completely gather all the data that I require or do the counseling that you need to receive. In rare cases, if you have an incredibly complex case, the extra time spent may be a bit longer.
However, my office staff will be pleased to provide you, either by phone or in writing – by US mail or e-mail – a list of the fees for the various services which you may expect to have rendered to you here at CWI. If for any reason you feel that our fees are simply too high or unreasonable, it is your right and privilege to pursue a relationship with another medical care or mental health care provider. If, on the other hand, you particularly want to see me but simply do not feel that you can afford the fees, you should know that my office manager can discuss other payment arrangements that may reduce the economic burden on you. We offer a credit plan for our patients and clients who cannot afford to pay for all of their costs initially, and this plan allows installment payments to be made.
All cases are evaluated on an individual basis. I do provide charity care to deserving people; it is my personal belief that no one should be denied excellent mental health care or medical care from compassionate physicians and clinical care providers simply because of poverty. There is obviously a limit to how much charity care I can give away and stay in business, but we try to be fair.
THE PRIVILEGE OF SERVING YOU
Now for some good news! It has always been our belief that it is a privilege and honor to serve our patients. To this end, we offer an enormous array of free and virtually unheard of services to our patients and clients. I have an extensive video library – covering topics from depression, to insomnia, to ADHD, to age management issues, to low-glycemic eating and beyond – which I frequently have patients view at no additional cost in my office following my making a diagnosis. This serves to educate you and your family about any condition that we might diagnose so that you can understand the condition and its proposed treatment perfectly. For the convenience of my pediatric patients, I provide amusing videos as well as a Nintendo game to occupy their busy little minds and fingers while I talk with the parents.
Filtered water, coffee, tea, and Tylenol are all available for the asking, and it is my staff’s position that they will attempt to honor any reasonable request that you may have while you are our guests here at the Institute.
My professional stance is to give you the best and most state-of-the-art medical/psychiatric treatment which is available, and that is the goal of all clinicians at support staff here at CWI. This comes directly from the education which I have been privileged to receive in the past and many wonderful and outstanding teachers that I was honored to learn from. In order to stay current, I spend hundreds of hours each year in continuing medical education activities; my ongoing continuing medical education is also contributed to, in no small part, by the extensive lecturing and review I do on psychiatric, functional medicine, and age management medicine topics.
IF YOU HAVE A BILLING PROBLEM
If your insurance company should deny you an adequate payment, it will be my and my staff’s privilege to assist you in any disputes that you may have with your insurance company. To this end, I have been known to write extremely detailed and somewhat testy letters to insurance companies basically insisting that they provide to their policyholder the quantity and quality of the services that they are contractually obliged to provide. Unfortunately, I cannot and will not take the responsibility for paying the bill – that is your responsibility and you will be ultimately responsible if your insurance company does not pay. I and my staff look forward to being of service to you. You and I will have both a professional as well as a business relationship, consisting of my rendering services to you and your contractually agreeing to pay for them. Payment is usually expected at the time the service is rendered. Insurance companies sometimes try to “wiggle out of” or delay their contractual responsibilities to patients.
At CWI, we will do everything that we can in order to ensure that you get your fair compensation from the insurance company; however, ultimate financial responsibility rests with you. I believe in an open and honest relationship with our patients and clients where “no question is a dumb question.” This article has been written to assist you in understanding any possible billing disputes that might arise between you and your insurance company. I view my and my staff’s assisting you with billing and insurance problems as equally important to our therapeutic relationship as anything I do professionally. We I look forward to the possibiity of being of service to you and your family in the future.
Louis B. Cady, M. D.