The Affordable Care Act... Your Insurance, Your Problem

03/27/2015 01:49 pm ET | Updated May 27, 2015
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When I was a teen, I recall having the Cadillac of insurance plans. We could go to any doctor, hospital, or pharmacy and wave our insurance card around like it was an American Express black card. Everything was covered. In fact, I remember going to the pharmacy one day to pick up a prescription and being told that I owed a co-pay of fifty cents.

"What?" I exclaimed. "There must be an error with your system; I don't have a copay," I told the pharmacist. My mother later confirmed that our insurance company did, in fact, raise our zero dollar copay to fifty cents.

"What a shame," I thought, and, "What is this world coming to?"

If I would have known then what I know now about the future of health care insurance and reimbursement, I can't say for certain if I still would have pursued a career as a physician.

With few exceptions, there are no more "Cadillac" insurance plans, not even the "Platinum" Marketplace plan. A recent NPR blog noted that most Marketplace plans in New York don't even have out-of-network coverage.

And for the millions of people who are stuck with such restrictive plans, other recent articles have illustrated that it's nearly impossible for the insured to know if a physician is in their network and if their services will be covered before they are actually billed.

Insurance companies have adopted ambiguous terms, such as HMO, PPO, co-pay, co-insurance, deductible, in-network, out-of-network, tier 1, tier 2, tier 3, and so on. And if you're lucky enough to figure out what is covered, you still have to address the issue of where and when it will be covered. Is it only covered for a particular physician, lab, hospital or pharmacy? Is it covered now, or only after you pay your co-insurance, deductible, and/or co-pay?

I recently had a conversation with a patient who expressed frustration that their specialist didn't advise them that they would be responsible for the charges of a specific test that was ordered. "I expected him and his staff to know what my plan would and would not cover," he said.

As a physician who has dealt first-hand with insurance reimbursement and verification for my own private practice for over four years, I knew that as reasonable of a request that this may sound, it was an exceptionally difficult task for any physician or physician's office to accomplish.

I expressed my sincerest apologies that he incurred unexpected costs from the test that his specialist ordered. But, I also offered that it would be impossible for any physician to know what tests would be covered by his insurance with absolute certainty.

For example, if a physician sees hundreds of patients a week, each of those patients would have a different insurance plan. Even if the plans were obtained from the same insurance company, the details of each individual plan are going to vary for every person. If you multiply these hundreds of patients by the thousands of possible labs and tests that physicians order, it becomes easier to see our conundrum.

Although I agreed that the office could have at least warned him to verify with his insurance company if the test would be covered, ultimately his insurance was a contract between him and his insurance company. We, as healthcare providers, can't keep up with the individual details of every patient's insurance plan.

So when a patient asks, "Will this be covered?" unfortunately, the answer may sound like, "Your insurance, your problem." This is not because physicians are insensitive to each individual's financial situation; it's simply because there is no transparency in healthcare costs. This is by design. Insurance companies do not want to pay. By keeping the details of coverage confusing and vague, they are able to pass more costs onto you.

It was recently reported that over 16 million people gained health insurance through the Affordable Care Act. To be sure, we have accomplished a tremendous feat by creating a heroic drop in the number of uninsured people in the United States. But I must ask, "Now that we have more health insurance, when will we have better health insurance?"