Current Health Care Issue – Confusion in Healthcare Billing and Insurance Costs

Current Health Care Issue – Confusion in Healthcare Billing and Insurance Costs

The experience of working in long-term care for fourteen years has provided educational opportunities for me to learn about the day-to-day operations of billing patients and insurance for services provided. In long-term care, one of the main issues is the cost of healthcare to the patient and whether the patient can afford it or not. When a patient receives a large bill for services provided, but the provider does not have the correct insurance information, this will create misunderstanding and confusion. Many patients then experience confusion and often call the provider with questions because they don’t understand the bill or insurance’s explanation of the benefits statement.

Many healthcare practitioners are now employed by private insurance companies that want them to maximize profits and minimize costs (Chem, 2014). When visiting a hospital or primary care physician, then we receive one bill. It is very difficult to accomplish this because the billing process has multiple loops before it becomes the patient’s responsibility. For example, the provider must bill the insurance company. Once the insurance company decides to pay the claim, then it sends the facility and the patient an explanation of the benefits. The explanation of benefits informs the provider of the remaining portion that is not covered by the insurance, which becomes the patient’s responsibility.

When a patient decides to enroll in an insurance plan through his/her employer, the patient agrees to the insurance-covered benefits. Patients choose to take their medical insurance through their employers while private insurance plans decrease in number because companies are looking for ways to reduce costs (Government pays the majority of US healthcare costs, 2008). If this occurs, patients will lack healthcare coverage. Many insurance companies have decided to provide their customers with the option to enroll in plans with higher deductibles. The problem that occurs is that the patient doesn’t understand the details of his or her insurance plan. The patient ends up paying a significant amount of money because of the high deductible. Many patients obtain their healthcare coverage through their employers. Many companies do not have a human resource representative who can explain healthcare plans. The cost of premiums is increasing. The rising cost of healthcare will continue if employees choose not to enroll in employer insurance benefits.

An increasing issue that is occurring is that physicians are billing for unnecessary services that may not be warranted. For example, my daughter went to the physician’s office and was seen by a physician’s assistant. According to my insurance, I should have only paid a thirty-dollar copay. Since the physician who oversees the physician assistant is credentialed with the insurance company with a specialty in cardiology, the provider billed the service as a specialist. This increased the copay to forty-five dollars. My daughter went for an upper respiratory infection. She never received any cardiology services. When I spoke to the insurance company and provider’s office, they said they were not going to change the billing claim. The insurance informed us that it’s the way the provider is credentialed. When providers bill for services that do not necessarily meet the guidelines of what was provided, then the patient might decide to choose a new provider. In today’s healthcare financial world, reimbursement rates are terrible, and the increase in the cost of technology is on the rise (Haugh, 2001). From personal experience, my wife and I contemplated looking for a new provider. The only reason why we are staying with our current provider is because the children are comfortable. Ultimately, patients have choices, and they will go where they feel they are not being taken advantage of by medical providers.

In conclusion, medical facilities need to review their billing practices to assist patients desiring to receive medical care. Patients do not want to go to medical providers because they are worried they will receive a large bill that will cause them a financial burden. If medical providers and insurance companies educated patients on their explanation of benefits and billing statements, this would reduce the misunderstandings and confusion that patients experience. Another problem is that providers need to be willing to work with patients who receive large bills and are unable to pay them. Providers end up sending them to collections instead of trying to develop some sort of financial counseling to assist patients with these large balances. This will allow the patient to feel confident about addressing their financial matters. In America, the healthcare industry needs to be altered to cater to the patient. Many healthcare companies are trying to make money and forget about the actual reason they exist. The healthcare industry needs to work with patients so that they can achieve the goal of providing quality healthcare at a reasonable cost.

References:

Chem, G. (2014). Lean and mean health care: financialization and the ACA. Against the current, 29(2).Retrieved from: http://web.a.ebscohost.com.ezhost.utrgv.edu:2048/ehost/pdfviewer/pdfviewer?vid=5&sid=4e8302e8-54c0-470c-ba06-20dd90b50fe3%40sessionmgr4007

The government pays the majority of US healthcare costs (2008). PharmacoEconomics & Outcomes news, (566), Retrieved from: http://web.a.ebscohost.com.ezhost.utrgv.edu:2048/ehost/pdfviewer/pdfviewer?vid=12&sid=4e8302e8-54c0-470c-ba06-20dd90b50fe3%40sessionmgr4007

Haugh, R. (2001). BACK TO BASICS. H&HN. Hospitals & health networks, 75(1), 32. Retrieved from: http://web.b.ebscohost.com.ezhost.utrgv.edu:2048/ehost/pdfviewer/pdfviewer?vid=5&sid=1d84fa65-0a00-4cad-9bf7-fc55f00076a9%40sessionmgr104

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Present your position on a current healthcare issue on a one-page basis. Following the assignment guidelines below. You can select your issue topic from newspapers, national news magazine articles, professional journals, or professional association literature.

Current Health Care Issue

Be quickly and easily understood.

Be succinct and clear.

Appear very professionally with the legislator’s name and title on top and your name and your credentials at the bottom.

Condense essential information in one single-spaced page, excluding the title and reference list pages.

Clearly describe the issue that you are addressing in the opening paragraph.

Include 3–4 bullet points regarding why you are seeking the legislator’s vote, support, or opposition. Bullet points should be clear and concise but not repetitive and should reflect current literature that substantiates your position.

Summarize the implications for the nursing profession and/or patients.

Conclude with two recommendations that you wish to see happen related to your issues, such as a vote for or against a change in policy or the introduction of new legislation.