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How insurance companies police doctors through arcane policies

Health insurers are micromanagers to the max – especially when it comes to dictating what care a patient can receive . . . and when.

Insurers never miss a chance to make getting healthcare harder, do they?

A new report from Modern Healthcare claims both Horizon Blue Cross Blue Shield of New Jersey and Cigna are planning to “crack down” on providers “performing unscheduled procedures.”

Which begs the question, what do health insurers think physicians actually do?! Because when it’s put like that, it sounds like doctors are hacking off limbs in dark alleys, and we need a crusader to save us.

But no — this big, bad “crack down” will interfere with doctors who need to draw blood, perform a skin biopsy, or conduct an electrocardiogram for unexpected reasons.

Wow. We sure are glad that Cigna and Horizon BCBS are cracking down on these egregious “medical malpractices.”

It all comes down to code claims. Sometimes during a patient visit, providers will identify a significant, yet separate, service that the patient needs — Modern Healthcare uses “removing a mole” as an example — and these services are coded as a ‘Modifier 25’ claim. And insurers are quick to deny Modifier 25 claims.

If insurers get their way patients and doctors will face additional roadblocks, including having to make separate appointments, managing schedules, taking time off work, enduring long wait times between visits, forking out additional co-pays, and sending multiple authorization records . . . just to separate a patient’s medical care into multiple appointments. Not to mention the fact that this is a giant waste of a provider’s time — and a hospital’s resources — in a time when health systems across the country are short-staffed and strapped for cash.

Health insurers have already lost lawsuits related to denying Modifier 25 claims. Oh — did we mention that, according to the California Medical Association, Cigna’s policy would add an extra $3.30 in administrative costs to every Modifier 25 claim filed? It may seem like a nominal charge, but with roughly 17 million US members, that no small change.

So, what about this policy policing makes healthcare more affordable or efficient? Would insurers really prefer doctors tell patients, “I’d love to do a blood test about this new condition you have, but I guess you’ll have to make another appointment first”?

According to the article, “The health insurance company did not specify in letters to providers why it was increasing scrutiny of modifier 25 claims.”

One doctor in San Diego has a theory: “‘This is just an administrative hassle to try to get the physician not to do what they’re supposed to do, and entitled to,’ said Dr. Ted Mazer, an otolaryngologist in San Diego and former president of the California physicians’ organization.”

Policing for policing’s sake, we guess.

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