These are interesting times for healthcare providers and patients. With a few exceptions, the Patient Protection and Affordable Care Act has mandated all U.S. citizens must purchase health insurance. It is estimated this will bring millions of previously uninsured people into the healthcare system and many will be confused about their insurance coverage.
While having access to health insurance will enable those with chronic conditions such as back pain to receive medical attention, these newly insured patients face the challenge of making sense of insurance recommendations which are tied to payments. Understanding these complex insurance coverage criteria requires the patient become more engaged in his/her healthcare. Some feel this will lead to better outcomes.
According to the National Patient Safety Foundation, studies show that more engaged patients have lower costs and better health outcomes. Unfortunately, the nonprofit organization notes the vast majority of Americans "remain relatively uninformed and passive recipients of healthcare services and thus lack the confidence and skills need to fully engage in their healthcare."
Diagnostic testing is critical
One of the primary areas where patients are not engaged involves diagnostic testing. Some medical practitioners have noted health insurance companies suggest lower cost tests or treatment which might impact the patient's health. We asked Plano-based Texas Back Institute surgeon, Jack Zigler, MD, if this has been his experience.
"Over the past five years, we have seen insurance companies take more control over authorization for diagnostic testing as well as for treatments," Dr. Zigler notes. "Often they will claim to rely on 'guidelines' which are not endorsed by any medical society, but are clearly written from a payer's (insurance company) perspective."
He continued, "They will use these guidelines to deny tests that doctors recommend, placing both doctor and patient at risk. They have also adopted the tactic of unilaterally considering FDA-approved treatments as 'experimental and investigational' and denying authorization for them."
Someone who is new to insurance might be tempted to assume the companies are patient-focused. So are these insurance recommendations based on costs or medical considerations?
"They are always based on costs," Dr. Zeigler noted. "They are always biased towards sparing the insurance company from paying for tests or services."
Have you ever had a patient who was adversely impacted by an insurance company recommendation?
"Our patients are frequently denied testing such as MRIs, EMGs, diagnostic nerve blocks and surgical procedures such as artificial disc replacement and coflex which are considered standard of care," Dr. Zigler said. "We have had patients become reliant on narcotic pain relief, lose their jobs and lose their families due to insurance company denials for needed care."
"We have had patients forced to choose a poorer surgical alternative, for example, fusion because the preferable recommended procedure, for example disc replacement, was denied," he concluded.
What should a patient do when they are given a recommendation and they feel it might not be appropriate to their condition?
"If they have the time — several months — they should follow the appeals process in their insurance contract," he noted. "They should call the insurance company daily to complain. They should contact their congressperson and ultimately they should contact an attorney."
What tests are crucial to spine and back pain treatments?
"Good imaging such as MRI scans, CT myelograms are often crucial," he noted. "They are either denied, or are referred by the insurance company to low cost providers who supply the doctor with a sub-optimal, often unusable product. Other tests such as diagnostic injections, discograms, EMGs are frequently needed but are often denied by insurance companies."
Do the physicians at Texas Back Institute encourage patients to ask questions about their treatments?
"Patients at TBI are absolutely encouraged to question their care, ask about alternatives, and get involved in their treatment program," Dr. Zigler noted. "We also encourage our patients to take an active role in questioning decisions made by their insurance company that are clearly not in their best interests."
If you have back pain caused by injury or wear and tear, you can be assured Texas Back Institute will use the latest equipment and expertise to properly diagnose and treat your pain. If you have questions about your insurance and our treatment, please click here and one of our insurance specialists will respond immediately.