The healthcare reform bill has passed in the US Senate. However both the US House of Representatives and the US Senate bills have yet to address important details affecting patient care. Oversight concerning the determination of medical necessity as well as provider network inclusion issues have greatly affected medical reimbursement and patient access to care. Many insurance companies reimburse medical expenses based upon a determination of medical necessity by the carrier’s claims department. In the absence of external oversight or regulation, the insurance carrier is free to deny care solely based upon their on private internal review.
Another key issue not addressed is how provider networks create financial barriers to care. Many insurance carriers reimburse medical expenses at lower rates or refuse reimbursements for out-of-network providers. Medical practitioners may also be excluded from insurance company networks for a variety of reasons. Practitioners may be required to limit medical procedures for patients and the number of office visits as a precondition for inclusion in the insurance network. Medical practitioners may also be required to accept lower rates of reimbursement for services provided to patients as another precondition to network inclusion. Some medical networks charge medical practitioners a fee for inclusion in networks.
The patient’s right to choose their own medical practitioner is not federally guaranteed by law. Additionally, there is no guarantee an insurance company will pay for medical services and patients often have no way to determine what will be paid until after a claim is submitted and a response is generated the insurance company’s claims department. The federal government seeks to mandate health insurance coverage for all US citizens yet has not stipulated that insurance companies must reimburse patients for medical expenses nor is there language to address oversight of the determination of medical necessity.
The determination of reimbursements is often based on what is termed as ‘usual and customary.’ Insurance companies have sole discretion over this aspect of reimbursement for general health insurance policies and may choose to exclude many procedures, office visits, and medical tests whether or not teams of doctors agree that such medical services are vital to the patient’s survival, recovery, or comfort.
The US House of Representatives and the US Senate have not addressed these details which represent core issues affecting healthcare outcomes for patients. Until these unresolved issues are rectified, it is unclear whether or not US citizens with health insurance coverage will have adequate access to medical care.