Five Reasons Not to Take Assignment
by William D. Esteb
To someone who has never filed a health insurance claim for chiropractic care, I approach the concept of third-party pay in a very different way than someone who rifles through the mail each day looking for the envelopes that reveal the words, "Pay To The Order Of" showing through the window. Perhaps I'm just fortunate for not having been rear-ended, slipped on some ice, or lifted something incorrectly at work. I've never depended upon someone else to step in on my behalf to pay for the restoration of my health. I realize that makes me something of an anomaly, but what's new?
After first being intrigued by the notion that a big insurance company will pay top rates for a patient's care, and then being all but dependent upon this type of arrangement for patient after patient, it is only natural to believe that having help from a third-party is the only way people will receive appropriate health care. Of course this isn't true, but after hundreds, maybe thousands of patients parade through your office looking to some deep-pocketed insurance company to pick up the tab, it may seem that practice just wouldn't be possible without their help. This belief is apparently so prevalent, that countless chiropractors have sold out their philosophy and their reasons for even getting into chiropractic, for the privilege of filing insurance claims on behalf of their patients. Many doctors emerge years later from their insurance induced stupors, only to wake up today on the "morning after" to see the remains of the wild party. Hundreds of patient files for whom you can barely put a face; a history of rampant staff turnover; and a gnawing sense that something isn't quite right. This is one hangover that won't go away by simply filing another claim and crossing your fingers, hoping that it doesn't get cut by more than 50%.
Some would say that the medicine to treat this terrible disease is worse than the disease itself. Yet, these are the skeptics who haven't hit bottom yet or who are able to maintain a more modest personal lifestyle on the crumbs that have dropped from the managed care table.
For those ready to take the plunge; those who want to reclaim their practices from the incursion of third parties; those who are prepared to avoid the path of least resistance, here are five reasons to stop taking assignment.
1. Patients don't value your services. Simply put, what we don't pay for, we don't value. When patients come and go as they please, knowing that an insurance company (or the government) will pick up the tab, they rarely place true value on the service provided. Ever notice the way automobiles are treated that are gifted to adolescents from well-intentioned parents? They are rarely maintained as well as a car purchased by the teenager down the street with his or her own hard-earned money. Same with the respect many patients show you and your office.
Perhaps more telling are the number of patients who continue with their care after the third-party has cut them off. Converting patients to a cash practice, especially later on when they're feeling better, to suddenly reach into their own pockets and pony up $25 or more for an adjustment is difficult, if not impossible.
2. Reduces the patient's coverage. While many chiropractors think they are doing their patients a great service by taking care of all the paperwork on their behalf, the reverse is actually true!
Remember, the insurance contract is between the patient and the insurance company. You are the real third party, who, by filing the paperwork for the patient, is immediately suspect. When you file the paperwork, the patient's case is monitored like a hawk. The unfortunate result, is that the net benefits that the patient ultimately enjoys, is reduced. But hey, thanks for the help.
It is more likely that patients will get fewer questions, better reimbursement, and less hassle if they file their own paperwork. Explaining this simple observation to patients would reduce some of your own staffing needs, its associated overhead, and the costly distraction from your primary purpose, which isn't begging to a minimum wage clerk to approve the patient's claim, is it?
3. Exposes you to federal laws. What a lot of chiropractors overlook is that when they or their staff completes a patient's claim form and drops it in the mail, crossing your state's border, your activities are suddenly subjected to a whole set of federal statutes. These oppressive laws include the RICO Act, not to mention potential racketeering and mail fraud issues. If certain sphincter muscles are starting to tighten, read on!
While I don't know of a single publicized case, the fact remains that should there be. . . ahem. . . certain. . . Shall we say inconsistencies, or even honest mistakes in certain fees, billing errors, or discounts afforded some patients, but not others, well, you may find you've become the love slave of "Bubba," your cellmate at the federal pen.
4. It further socializes our culture. This argument may be lost on those who are oblivious to politics, and it may be subtle, but I still think it's important. How was health care paid for a hundred years ago? Not by Blue Cross or Blue Shield! People had to reach into their savings, sell livestock, or go into debt and experience tremendous financial hardship. To say the least, this created an incentive to take care of oneself. Something quite lacking these days.
Today, a growing number of patients could care less about the costs incurred by their ignorance, neglect, poor health habits because a third party picks up the tab. The current arrangement practically encourages patients to live irresponsibly, knowing that big brother will make things right. Ultimately, this produces a generation of patients who live for today (if it feels good, do it) and come to expect that others should pay for their indulgences. When you accept insurance assignment, you isolate patients from the consequences of their behaviors. In effect, you can inadvertently sanction a lack of personal responsibility.
5. It endorses a limited view of health. I can't think of a single thing that plays into the hands of the medical-industrial-complex more than chiropractors accepting assignment. It is a tacit agreement to only treat patients' symptoms. Upon close examination, health insurance isn't about assuring one's health, it's about sickness treatment.
Chiropractors who attempt to lead their patients into a wellness lifestyle, whose cornerstone is some type of regular chiropractic checkups for life, discover this problem all too late in the relationship. They've hastily, even greedily, accepted assignment at the beginning of care, with the notion to use the subsequent visits to enlarge patients' understanding of true health and convert them to their cash plan on the exact same visit their insurance company finally declines coverage. If that's working in your office, you might try your hand at timing the stock market or investing in heating oil futures!
The fact is, there is probably no greater way to get your patients' attention about your true motives and grand mission on this planet, than to decline the honor of filing their insurance paperwork for them. Any compromise, and your hopes of keeping them, much less encouraging their family to begin care, is merely a pipe dream.
I know what you're thinking. You're thinking that at least of few of these arguments make sense, but in the real world, if you don't take assignment patients will pack up and go to a chiropractor down the street who does take assignment.
I don't think so. Who taught patients that the concept of assignment even exists? I certainly don't see assignment discussed in the yellow page advertisements of physicians and medical doctors. However, I will admit that if you're going to fight the currents and abandon this counterproductive vestige of a previous time, you'll need to change more than just your financial policy.
First, you're going to have to communicate with your patients. Doctors can no longer afford to delegate the review of your patient financial policy to staff members. There are a few exceptions in which staff members are better at it than the doctor's inclination to give away the store, but face the music and build up some calluses. The clinical relationship the patient hopes to benefit from is between the patient and the doctor--not the staff. Tell `em how it's going to work.
Second, realize that most patients don't have the faintest idea that the possibility of assignment even exists. So, if the subject comes up (it rarely will) you'll have to explain the patient benefits of filing themselves. Offer the super bills, reports, and the documentation they will need in a timely manner, but explain why it's in their best interest to attend to this little matter themselves.
Third, and this may be the most difficult and most important, don't let your body language give you away!
If you're inclined to adopt a no-assignment policy for one or more of the reasons I've suggested above, there's no need to draw a line in the sand and change your policy forever, starting tomorrow morning. Simply decide that it's your policy--for just the next new insurance patient. Instead of holding back even a little, present your policy with power and conviction--for just the next new insurance patient. If you get rejected (you won't!) then immediately revert back to your old, time-tested ways. Instead, I think you'll be pleasantly surprised.
Striking a Nerve
Originally published in 1996
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