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Repeal and Replace Debacle Not All Bad News for Physicians


The AHCA would have likely brought back "post-claims underwriting," which would have been bad news for physicians.

In the aftermath of the news that House Republican leaders had pulled the bill to repeal and replace the Affordable Care Act (ACA) with what was called the American Health Care Act (AHCA),  physicians can breathe a small sigh of relief.  The insurance industry sought to have included in the failed bill  a return to what was known as "post-claims underwriting." In other words, a repeal of ACA's ban on the use of "pre-existing conditions" as a reason to deny coverage (or more likely, rescind a policy after it became clear the patient might require expensive care ).

Physicians are only now beginning to awaken to the realization that simply utilizing more benefits than your "peers," will get you targeted for attention from special fraud investigations units of major insurance carriers. They  may well not recall the original group upon whom this was practiced, the idea of defining "fraud" by "utilization." 

Prior to the ACA in 2010, insurance companies were free to deny coverage to insurance applicants on account of "pre-existing" conditions.  The logic couldn't be simpler. Just as you shouldn't be able to purchase automobile insurance to repair your car after you have slammed into the neighbor's fence, you shouldn't be able to purchase insurance for an illness or injury sustained before you purchased insurance.  Post-claims underwriting involves waiting for a claim to occur and then attempting to prove an applicant "lied" on an application. This way, insurance carries could spend less on underwriting, and simply wait for the unhealthy to self-identify. Even if insurance application had been approved, the insurance company could "review and rescind" the policy. 

Again, it sounds reasonable. No one is in favor of "insurance fraud."  However, "fraud" is in the eye of the one benefiting from the allegation.  Cardinal Richelieu, the French statesman from the 1600s famously said,  "If you give me six lines written by the hand of the most honest of men, I will find something in them which will hang him."   

Insurance companies were often happy to take anyone's insurance, with only a cursory review of  the patient's medical history, then wait for a patient to fall ill with an expensive disease or condition, comb the paperwork, find the slightest deviation from "perfect documentation," and then deny the hospital and physician's claims for benefits.   Although, the patient got stuck with a medical bill he would never pay, it was the physicians and hospitals who were left holding the bag.  

It would be wise to keep an eye out for any new attempt at "repeal and replace." Maybe it is true, if we return to pre-existing exclusions and post-claims underwriting, premiums may go down.  But if we do, I fear once again, it will be physicians left holding the bag.

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