As a private medical clinic, we are often caught in the middle between the patient and the insurance company. 

We often get calls or letters from our patients with billing inquiries. They will ask us why we have charged them more than their coinsurance or question why a particular procedure or a particular ancillary service isn’t covered by their insurance policy. When I’m unable to answer their questions, they will often get frustrated or upset. Why don’t you know, they ask. The answer is simple: it’s their insurance policy and I have no idea what their particular policy covers or doesn’t cover.

Some things I can tell them. I can tell them if their insurance policy requires preauthorization or pre certification for a procedure. I can attempt to get those authorizations for them. If the authorization is denied, I can appeal, but any further denials are between them and their insurance company. Medical policies are also something I can go over with them.

Medical policies or local rules are explanations or guidelines by an insurance plan of what they will cover based on certain diagnosis and what they won’t. Some procedures they will identify as “investigational” or “experimental.” Different insurance companies have different rules. For example, one insurance company recently decided that two procedures that it previously paid for and that are widely performed and accepted methods of treatment are now investigational or experimental. These policies vary from insurance company to insurance company. They can and do change.

Solo practitioners not employed by insurance companies. We are self-employed. If we are contracted with the insurance company as a participating providers, all that means is that we’ve agreed to take reduced reimbursement and abide by the insurance company’s rules about authorizations, coinsurance, and deductibles. As a solo practitioner, we must let you know what an insurance company ‘says’ about a particular treatment. If the insurance company tells us that they won’t guarantee payment for a treatment, we will ask you to sign an advanced beneficiary notice advising you that the insurance company may decide that there is no medical necessity for the doctor’s recommended treatment. After your insurance receives your claim, they tell us what we can and cannot bill you. If we don’t abide by what they dictate, we are in violation of our contract.

In fact, the insurance company is just as interested in not paying me as they are in denying you a service.

In essence, we are caught in the middle. We want to do the best job for our patient; but we have no way of ensuring that an insurance company will pay for your services. Please understand that we will always try to do our best for you, but the best advocate for you with your insurance company is you.

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