Insurance Claim Challenges…A Problem More Insidious Than Fraud

healthinsuranceInsurers cite rampant insurance fraud and declare escalated costs due to over-billing providers and pain-focused, manipulative claimants.  I don’t doubt unscrupulous providers or claimants are a problem, yet I wonder if the practices of insurance companies themselves are contributing to a larger concern…one that threatens the very integrity of care where a third party pays for therapy.

In a recent discussion on social media, I shared how an insurance adjuster and I engaged in a very congenial conversation “across the fence”.  The adjuster asked why – despite the Financial Service Commission of Ontario (FSCO) Professional Services Guideline (PSG) “maximum hourly rates”http://www.fsco.gov.on.ca/en/auto/autobulletins/2012/Documents/a-03-12-1.pdf  – would I submit an invoice for my regular fee.  She was genuinely concerned that the claimant would bare the difference and couldn’t understand why I wouldn’t work at 2/3 my standard fee.  “Doesn’t your regulatory body mandate this?  Don’t RMTs know the fee schedule?” she inquired.

I maintained a friendly discussion, sharing my experiences both representing the professional association at insurance negotiations, providing assessment in Designated Assessment Centres (DACs), and as a practitioner working with auto-insurance claims for many years.  I didn’t ask, but perhaps I should have, “If you showed up tomorrow and your employer expected you to do the same work at 2/3 pay, would you?”  This is the essential point that the Financial Services Commission in apparent collusion with the insurance industry during the 2010 changes to auto-insurance in Ontario seemed to miss…practitioners set fees based on market forces and in consideration of operating costs and profit/loss parameters.  An imposed, arbitrary fee schedule doesn’t eliminate these considerations, and in fact only spurs providers to game the system and look for other ways to make ends meet.

It appears that “maximum hourly rate” has been translated by the insurance industry and their government cohort to mean “the practitioner should not bill more”.  I’ve been privy to RMT discussions where insurance adjusters in fact chastised the RMT for billing their standard rate, discouraged the claimant for paying a co-payment, and complained to the RMT for even considering such practices, suggesting they were in some way unethical.  Insurance industry pundits appear not to account for the practitioner’s operating costs or break-even point…although the insurance industry’s posted record-breaking profits seem to indicate they are well aware of their own.

Further, the PSG states, above the section re: Maximum Hourly Rates that “Insurers are not prohibited from paying above any maximum amount or hourly rate established in the Guideline.”  So how is the practitioner acting unethically in billing their standard fee if the insurance company has within its ability to pay it?

A shout-out to the insurance adjusters out there – providers working in this insurance system risk having claims denied, have to prepare extra paper work and wait 30 days or more for payment, while in the non-third party marketplace patients/clients are willing to pay full fees without risk or wait required of the provider.  The current system provides real dis-incentives for providers…don’t be surprised if you don’t get the behavior you had hoped for.

WSIB (Worker’s Safety and Insurance Board) holds even more uncertainty in my experience, and is even more closely tied with government operations.  In the last 3 work injury claims I’ve applied to WSIB for, all have been turned down flatly even though they were legitimate work injuries.  Reasons cited,  “The claimant took too long to file (3 weeks) so it can’t be work related” and “Well they’re already working with a physiotherapist so they don’t need massage.”  No exploration into my findings, no questions re: my clinical rationale…just a flat “no”.  http://www.wsib.on.ca/

Further, the WSIB has worked into policy that a provider cannot bill the patient the difference between what the WSIB pays and the provider’s regular fee schedule.  The provider if they accept the case must as well accept the loss.

Let’s turn for a minute to the real inequity auto insurance forces on employers paying for employee benefit plans.  Auto insurance regulation requires persons injured in an auto accident to supplement their care first through worker benefit plans.  This means those benefits are unavailable for the reminder of the benefit cycle for other work-related health concerns the employee may have.  Auto insurance premiums are paid by the claimant…why are employers implicated in paying the initial bill?  Why are employers not screaming?  I imagine every Chamber of Commerce, every small and mid-sized business, every corporation and all their employees would have something to say about this policy.

Provider professional associations play a role in advocating members’ interests to government, the insurance industry and gatekeeper health professions to ensure opportunity to bill for rehabilitation services.  Reimbursement despite legitimate claims is not automatic, and in some cases must be fought for.  The Canadian Massage Therapist Alliance http://www.crmta.ca/?page=10 has as a primary focus meeting with the “Canadian Life and Health Insurance Association, the Canadian Health Care and Anti-fraud Association and individual insurance companies on issues of mutual concern.”

Should RMT associations across Canada pool resources in support of the CMTA, work accomplished would be exponential.  Despite requests by members at every Annual General Meeting, the board of the Registered Massage Therapists of Ontario repeatedly decline the opportunity to be involved.

The insurance industry presents as a health care hegemony, maintaining in some cases untrusting and manipulative relationships with both providers and claimants, spinning fraud and abuse to an ill-informed public and media.  Claimants and employers pay insurance premiums dutifully and expect some compensation when calamity strikes.  A “Good Neighbour” the insurance industry is not.

What would be a better solution? i) Ensure an automatic level of compensation in both auto insurance and WSIB that can proceed immediately for the patient’s interest.  Auto insurance has the Minor Injury Guideline, which in many respects is a good model. ii) Allow claimants to pursue further funding through litigation against the offending party if their cases are complicated iii) Allow claimants access to the regulated health provider of their choice, limiting bottlenecks and power differentials currently employed in a gatekeeper-driven model iv) Ensure transparent accountability by insurance companies, providers and claimants v) Do not dictate fees, but require measured outcomes and intermittent reports to show progress.

A more radical approach is to employ health and insurance trusts where forced-spending on behalf of citizens towards their personal costs are then are directed by the claimant as they see fit.  No large, profit-centred insurance industry determining access to care, no claims denial or years of litigation and appeals trying to get fair treatment, and an information-savvy citizen putting their dollars where they are best invested.  What do you think?

2 thoughts on “Insurance Claim Challenges…A Problem More Insidious Than Fraud

  1. Dear Don,
    I very much enjoy reading your emails. It is great to have an advocate like you for our profession.
    Your most recent comments on insurance claims I was very pleased to read. I have had similar discussions with several insurance claim adjusters. My approach to this “dilemma” had been to include a time increment breakdown on how I spend the hour with the client and the associated cost of treatment; my fee is $88 (HST included). I also quote from the introduction of the Fee Schedule that insurers are not prohibited from paying above the “maximum allowable fee”. In the last few years I would say that maybe 90 percent of companies have paid in full.
    Your article will help educate therapists, especially those new to the profession, and perhaps inspire those who feel they “cannot” be paid their rate an therefor often don’t take on MVA’s to take a stance with the insurance companies.
    Please Keep up the good work.
    All the best.
    Yours in health.
    Sue Robson RMT
    Touch Works London
    P.S when I graduated back in 2003 I read your 1st book which was very helpful and have been encouraging many others to do the same.

  2. Although I have practiced for several years, I have rarely needed to deal with insurers, and for that I am glad. I appreciate your efforts on this issue though because frankly I consider it an affront to the legitimacy of assage therapy.
    Keep up the good work!

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