When Health Plans Come between Patients and Physicians

March 31, 2014

Sometimes insurance companies get between patients and their physicians; especially this time of year when health plans make changes.

The first quarter of every year is tough insurance-wise - both for patients and the practice. Plans are changed by employers, formularies are changed by the plans, deductibles are renewed, etc. Patients aren’t always aware of the changes.

This has been a particularly bad quarter. Many patients who have been stable on their meds for years are receiving letters (as am I) that they will have to change because their drug isn’t covered. I do what I can to try to justify keeping them on a stable regimen, but patients don’t always meet the criteria the plans require.

"Has the patient tried drug X?"

No, the patient has been on drug Y for eight years and has been stable.

"The patient has not tried and failed the formulary alternative, so coverage is denied."

Patients are being switched to plans that I don’t participate in. The problem is that we don’t know what their new plans are until they come in. Some of them don’t even realize that their plans are different.

I saw a patient today that I have been seeing for a long time. He still remembers when I was pregnant, and my kids are 10 years old and 11 years old. I will no longer be a participating provider in his plan. It was not of my doing. My associate still participates, so I told him that he could still come here and that he will get excellent care. He would like me to continue to see him and bill under my associate. I told him that I am honored that he feels so strongly that I be his physician, but that I can’t commit fraud. I reassured him that he would like my associate and that I am still around if he has questions.

I know that things cannot always stay the same, but I wish that insurance companies didn’t get between physicians and their patients.