Sunday, August 23, 2009

How to Play the Insurance Game and Win


Dr. Elaina George, Medical Correspondent – 

For Americans, receiving heath care is like going to a casino, but here the typical rules don’t apply. In the healthcare casino, the medical insurance industry, Big Pharmaceutical Companies and hospitals make the rules to insure that the house wins every time. Over the years they have increased your stakes by increasing premiums, drug costs and hospital costs, while raking in windfall profits. The medical insurance industry has grown larger and more powerful by systematically fleecing patients and doctors. To hide the fact that they are playing with people’s health; they have been masters of distraction. The ever changing rules for patients and doctors have made it impossible to learn what you need to know. Moreover, it has placed doctors, who are the face of medicine, in a position where the patient has begun to question their motives. This has eroded the doctor patient relationship and has damaged the foundation of excellent medical care.

Over the next several weeks, we will examine how the game has been rigged so that you can finally understand the rules. Each week we will expose what you need to know to take back your power and put the odds back in your favor so you can win! This week we will examine the medical insurance industry.

Basic facts about the medical insurance industry:

· The Players - Top Medical Insurance CEOs

· Most of the insurance companies are for profit corporations

· Doctors do not receive money for ordering tests

· Insurance companies use pre-authorization to control what tests a doctor is allowed to order

· When insurance companies set a doctor’s fee of “usual and customary” it is an arbitrary fee devised by the insurance company. It is not based on the doctor’s actual cost of doing business and

· Insurance reimbursement rates are based on Medicare rates

· Premiums have risen to pay for the insurance industry’s cost of doing business (including shareholders and CEO salaries), while reimbursements for doctors have dropped by about 60-70% over the last 10 years

· Although approval for a patient’s care may be approved by the insurance company, there is no guarantee that the insurance company will pay the claim

· Insurance companies have subsidiaries that work with pharmaceutical companies in order to make money by selecting what drugs your doctor is allowed to prescribe to you.

· Insurance companies invade patient privacy by buying lists from pharmacy clearing houses that document what prescriptions you have ever gotten. They use this information to deny coverage to new and existing members based on a ‘pre-existing condition’ even if you had only filled a prescription once.

What you can do to protect yourself:

· Read your insurance contract and if you don’t understand it contact your insurance company or human resources and ask questions

· Choose coverage that fits your medical needs as well as your budget. If you have chronic medical problems make sure that you choose an insurance company with a large network of doctors so that you have choice.

· If you currently have a physician and you are happy with their care, ask them what insurance company they belong to and ask them about access – specifically, if the insurance mandates pre-certification for services.

· Before you go to your doctor know your benefits, don’t depend on the doctor’s office to do it. For example, if you have recently seen a doctor or had medical care, that information may not be updated. Therefore, the status of your deductibles or co-insurance may not be current and that can affect what you have to pay.

· If you have been denied medical care by your insurance company and you have exhausted their appeals process, but still feel that you have been unfairly denied, you should contact the insurance commissioner in your state. The insurance commissioner is the main regulatory authority that can change a decision that has been made unfairly.

· Open your insurance bill (also known as an explanation of benefits), it will detail what was done by the doctor or hospital, the amount the insurance company paid and the amount you have to pay. If you have questions about what was done call the doctor’s office or hospital and ask them to clarify what was done and why. Honest mistakes can be made and rectified in a timely way when you are proactive.

Next week, we will take a detailed look at the pharmaceutical industry. If you have any questions please send them to or

Dr Elaina George is a prominent Board certified Otolaryngologist who practices in Atlanta. She started her practice Peachtree ENT Center with a mission to practice state of the art medicine that is available to everyone, and has come to be known as, the patients’ advocate. Dr. George graduated from Princeton University with a degree in Biology. She received her Masters degree in Medical Microbiology at Long Island University, and received her medical degree from Mount Sinai School of Medicine in New York. She completed her residency at Manhattan, Eye Ear & Throat Hospital. Her training included general surgery at Lenox Hill Hospital, pediatric ENT at The NY-Presbyterian Hospital, and head and neck oncology at Memorial Sloan-Kettering Cancer Center. She has published in several scientific journals and presented her research at national meetings. You can listen to her radio show Medicine on Call, and read her blogs as a medical correspondent for Your Black World .

To have Dr. George as a speaker, please reach out to or call S. Prewitt at (901) 413-0203.

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