THIS TIME ON CODE WACK!
Why can working as a doctor in America feel like being on a battleground? What questionable tactics are insurance companies using? How are they affecting patients and physicians alike? And when coverage is denied, what can patients do? (See Helpful Links below for tips on appeals.)
To find out, we recently spoke with Dr. Erica Rowe Urquhart, a private practice orthopedic surgeon in northern New Jersey. A Harvard-trained biomedical engineer with an MD and PhD from Johns Hopkins, Dr. Urquhart is the author of the forthcoming book The Invisible Hand Wielding the Scalpel: Paying the Price in America’s Fractured Healthcare System.
This is the first episode of a two-part series.
Check out the Transcript and Show Notes for more!
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SHOW NOTES
WE DISCUSS
You’ve described how the intersection of healthcare and health insurance is like a battleground today. Tell us about that.
Urquhart: “I think first we have to explore … the doctor-patient relationship, right? … generally speaking, patients come to us and either they need routine maintenance care or they need help with a specific problem that has just popped up.
“And then we’ve got this third party in this relationship, which is the financial arm. Right. The insurer.
“And what we are finding more and more in our practice, especially over the last 15 years, is that that third party has really begun to dictate what’s happening in the doctor-patient relationship.”
How are insurance-related financial and administrative pressures affecting your practice?
Urquhart: “… we have observed over the last 15 years that practices on the reimbursement side have become more and more, let’s just say suspicious … when … I first started in practice … , we would expect to be reimbursed within 30 to 60 days. That’s, you know, routine.
“ … currently it could be 60 to 90 days or depending on the additional information that’s requested, it could be six months on average. So there’s an irregularity to reimbursements and it’s extremely challenging to operate any business or any entity without having a predictable source of income. So that’s number one. There’s a stress factor involved there.
“And then beyond that, in the doctor-patient relationship, when we are trying to come up with a treatment plan for patients, we’re generally finding that there are more and more hurdles for us to be able to implement the treatment plan. Meaning this PA or prior authorization practice is expanding throughout health care and everything we do, almost, it feels that way, requires some sort of third party to say, ‘yes, we’re granting authorization’ …
Yet despite the patient having health insurance, sometimes the answer is “no?”
Urquhart: “The no and the entity on the other side, whomever is representing the insurance company, they will tell us frequently. ‘It’s not that we’re denying the patient care. So please don’t say it’s a denial. Actually, we are just saying we’re not going to pay.’
“[The patients are] paying their premium. So that’s a significant financial investment. Then they’re paying their deductibles, they’re paying their copays, so there’s significant out-of-pocket expense. And then these services, be it physical therapy or MRI or even surgery, they can be quite expensive. And as you say, a burden that is insurmountable.
“And what studies have shown is that up to 75% of patients are actually deciding not to have care or not to pursue a treatment plan because of the financial burden associated with the treatment plan and the issues that have come up with the prior authorization practices.”
Helpful Links
UpMed: The Journal of Healthcare’s Race To The Bottom, A Podcast by Dr. Erica Rowe Urquhart
Don’t fall for these myths on prior authorization, American Medical Association
Inside the prior authorization crisis: Adding costs to practices and delaying care for patients, Medical Economics
The Financial Challenges of Healthcare, Practice First”
Where to Start if Insurance Has Denied Your Service and Will Not Pay, Patient Advocate Foundation
This Little-Known Appeal Could Force Your Insurer to Pay for Lifesaving Care. Here’s How to File It., ProPublica
Episode Transcript
Read the full episode transcript.
Guest Biographies: Erica Rowe Urquhart, MD
Prior to graduation from high school, Dr. Urquhart was distinguished as “America’s Top Student Leader” by the National Association of Secondary School Principals and was recognized as Science Student of the Year at the California State Science Fair. Dr. Urquhart left San Diego for Cambridge Massachusetts as a Harvard National Scholar.
While at Harvard, she majored in biomedical engineering while completing her premedical requirements. Upon graduation from Harvard, Dr. Urquhart attended the Johns Hopkins University School of Medicine where she completed her M.D. and obtained a Ph.D. in molecular and cellular neuroscience in seven years.
Dr. Erica Urquhart was selected for orthopedic surgery residency at the Cornell University-affiliated, all-orthopedic Hospital for Special Surgery. As a resident, she was recognized by the Orthopedic Research and Education Foundation for her developmental biology research performed at Cornell University.
After completing orthopedic surgery residency, Dr. Urquhart joined her husband, Marc in private practice where they formed Urquhart Orthopedic Associates in northern New Jersey.
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