Taking Insurance

Surely one of the most ubiquitous euphemisms in medicine today.

Another professional (William Shryer at Diablo Behavioral Healthcare) subscribing to a listserv I read inspired me to write this with his comment on a frequent type of post: "Need psychiatrist in Omaha who takes Aetna [or some other brand of payer]." He advances this quaint idea that, rather than basing a referral on who "takes" which insurance, one should base referral on the qualifications of the provider and the clinical needs of the patient.

I imagine myself ordering two hamburgers, fries and a soda, and asking, "Do you take insurance?" like I might ask whether they accept checks or credit cards.

I imagine myself answering, when a prospective patient in our first telephone contact poses the same question, "I take money."

Insurance is definitely not money.

Taking insurance is a gamble. When the insurance company pays the provider, it is entitled under federal law, and some state laws, to say, "Gosh we didn't mean to send you that money after all. Please send it back now." And you have to send it back. I call it funny money. That applies even if the provider has not signed a contract with the payer. It's even stickier if the provider has agreed to the terms of the contract. Like the professional I mentioned above I contract with no payers, including Medicare. So I have not read one of those many paged contracts in some time. My objection arises from the fact that most of them appear to lead to the provider working, not for the patient, but for the payer, what I see as a conflict of interest.

But here's the catch: most patients cannot afford to pay our fees out-of-pocket, and many of those who can feel entitled to get something back for all those dollars they spend on premiums. I have to sympathize.

And which provider is most qualified? The provider who "takes insurance" from whomever offers it may have a very busy practice indeed. This may translate into lots of experience. Are quality and quantity necessarily at opposite ends of the spectrum? Would you rather have your appendix removed by a surgeon who does the procedure once a year or one who does it four times a week? Experience is not the only consideration though. The provider with the less busy practice may take more time and provide a more individualized approach. She may also have more time to return phone calls or schedule early appointments. Insurers usually verify credentials, attempting to guarantee at least a minimal level of competence, but providers who do not contract with insurers may stay busy enough to avoid contracting by virtue of referrals from other providers and patients who respect them.

That referral should take qualification and the clinical needs of the patient into consideration, and reimbursement may be necessary, but more patients might benefit from reading the provider's contract with the payer rather than pretending the provider answers only to the patient. Providers who complain about insurers but sign those contracts have no business complaining. They are enabling them.

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