The woman sat on the edge of the examining table, tears in her eyes. After a recent laparoscopic procedure to repair a painful condition, she was now healthy. So why was she crying? She paid her co-payment and pre-paid her deductible. The procedure was pre-authorized by her insurance company. She did everything she was supposed to do, and so did her physician. But when the bill came, the insurance company refused to pay. The woman had neglected to read the fine print on her policy that said, Pre-authorization is not a guarantee of payment. “It happens all too often,” says ob/gyn Dr. Teresa Knight, CEO of Women’s Health Specialists. “You pay your premiums and think you’re fully insured, but if the insurance provider changes its mind about covering a procedure, or if it goes bankrupt like HealthLink of Illinois did, or if you haven’t met your deductible, you get stuck with the bill.”
The insurance industry these days is like a never-ending round of Who’s On First. “They say they’ll pay for an annual exam or preventive care, but what’s actually covered varies from plan to plan,” Knight says. “You used to go in for a checkup with a list of questions, and if you had a specific concern, say, a lump on your thyroid, your doctor could check it out. Now you have to schedule, and co-pay for, an additional visit.” The Affordable Care Act can add to the confusion, she notes. “Anthem participates in the exchange, but its Pathway and Pathway X plans aren’t accepted by many hospitals and practices in Missouri,” she says. “Most patients didn’t know that when they bought it.”
Insurance and health-care costs have spiraled so far out of control that many patients can’t pay for uncovered, but necessary, treatment. “And if doctors don’t get paid, we can’t keep our doors open and help patients,” Knight says. Increasing numbers of physicians are being forced out of private practice because they can’t afford it, she notes. What’s the solution? Knight envisions a future in which insurance covers only catastrophic cases and major surgery. “Everyday health care could be covered by individual health savings accounts, where patients pay out-of-pocket on a realistic payment plan,” she explains. “By removing insurance companies from the process, health-care fees will return to realistic levels.”
Meanwhile, Knight urges patients to become educated consumers who know exactly what they’re getting for their insurance dollars. “Read your policy carefully, especially the fine print. It’s your responsibility to know if a procedure is covered, as it’s your responsibility to pay your medical bills. These corporations profit whether you get healthier or not. Doctors dedicate their lives to helping patients, but the basic trust between doctor and patient erodes when a corporation becomes the middle man. That’s why I listen to my patients’ frustration with their insurance companies— because I know the companies won’t.”
By Tony Di Martino
Pictured: Staffers Bridget Herroon, Lindsay Larson, Dr. Laura Eastep, Brandi O’Kelley, Dr. Teresa Knight, Jasmine Shell, Caitlin Kaufmann, Toni Uzzetta, Angela Misuraco and Nikki Blue. Not pictured: Julie Thompson, Diandra Trujillo.
Photo: l.o. imijri
Women’s Health Specialists of St. Louis is located at 456 N. New Ballas Road in Creve Coeur. For more information, call 314.292.7080 or visit whs-stl.com.
