Posted by: notdeaddinosaur | April 15, 2013

Whose Insurance is it Anyway?

Man comes in for a physical. Thanks to the new healthcare law, there is no longer a co-pay for this preventive service. He is pleased.

We notice that he has an unpaid balance from an earlier visit a year ago. We have billed it to his insurance, which denied the claim, stating that the visit was for a pre-existing condition and was therefore not covered. We explain this to the patient. He is not pleased.

He states that the previous visit was not, in fact, for his pre-existing condition of asthma (for which the documentation clearly states the visit was scheduled), but rather to discuss his erectile dysfunction, which he states is a new problem. Because it is not a pre-existing condition, the insurance should pay it. He is pleased to explain this.

Never mind that we evaluated, discussed, and managed his asthma during the visit (clearly documented) as well as his ED (also documented). Never mind that neglecting to include the asthma diagnosis on the claim would constitute insurance fraud. Never mind that we’ve gone round and round with the insurance company for six months, and then billed him for the next six months. Never mind that he has been told that his insurance contract is between him and the insurance company, whereas we are merely the ones actually providing him with medical care.

We request payment owed for services rendered. He is not pleased.

His precise words:

“I don’t think I should have to pay.”

Really? For services already rendered? Does he think the water, electric, and phone companies would be perfectly happy to continue providing me with services if I decided randomly that I shouldn’t have to pay for them? My lawyer and accountant would have me in small claims court in a jiffy if I decided after the fact not to pay up. Why are doctors any different?

Why do people seem to think that the terms of their contract with their medical insurance company doesn’t really apply to them?

Talk about entitlement!





  1. The other thing I would enjoy is walking up to the grocery store register and saying, “I know this loaf of bread is priced at $1.00. I’ll pay you $0.35.” But in healthcare it’s okay? Just sayin’…

  2. When I see a doc I give the particulars concerning both my primary and secondary insurance carriers. I’ve had it happen more than once that If the primary doesn’t pay for whatever reason, the doc’s office asks me to pony up and I have to tell them to bill the secondary, Most of my docs know this I would think that once I’ve given all my insurance coverages, all docs would follow through as a matter of course. Yes, if all coverages fail, I know that I’m on the hook but that has not as yet happened, except for an occasional small copay.

  3. not-so-COG:

    Most offices won’t file secondary insurances because of patients with attitudes like yours. You expect the office to file one claim, wait 30-60 days for a denial, file another claim, wait 60 days for another denial, and then bill you and wait for you to get around paying what you owe? They’d being better off seeing you for free as a charity case. Talk about entitlement.

  4. Not trying to make excuses for someone that, if they can afford it, should pay the doctor, BUT…the misunderstanding probably springs from the fact that “preexisting conditions will be covered by insurance” has been said again and again regarding the new health care law. People believe preexisting conditions should be covered, especially given the behemoth premiums people are paying right now. And historically, the way the United States’ insurance system has treated people with preexisting conditions has been nothing short of barbaric.


  5. @Nick: I agree that the whole “pre-existing condition” thing is an immoral racket. However, this whole incident happened long enough ago (remember, everything on this blog involving patients is extensively disguised) that there was no confusion about the new law. Suffice it to say, my ire was roused by the precise words, “I don’t think I should have to pay.”

  6. @ family doc. It appears to be your position that a patient has an “attitude” if that patient expects a medical provider, who has been given and has accepted the information concerning both primary and secondary insurance, to process bills accordingly. Is that is your position? If so, it would appear that secondary insurance, even if it is from a highly reputable insurer, is a useless sham.

  7. Sorry, dear, the provider is under no obligation to file your secondary insurance. Many do, as a COURTESY, but there is no obligation to do so. You ARE obligated to pay for services rendered. Your contract with the insurance company is your contract with the insurance company. Filing the secondary is up to you if the provider elects not to do that.

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