In a nutshell, insurance companies have many "tricks" that they can play upon your doctor. These tricks are not necessarily intended to be malicious; they are instead intended to generate or save money by not paying or delaying or reducing payment to your doctor. Your doctor may lose money because he/she signed a contract developed by teams of smart attorneys working for the insurance company or "managed-care" company. Here is a summary of some of the maneuvers (games) that managed-care companies may use on your doctor:

1. Insurance companies tell their employees to destroy the paper claims doctors send to them.
2. Insurance companies tell doctors to send claims electronically by computer, but somehow the company manages to "lose" the electronic claims.
3. Insurance companies put a six-month limit on doctors to protest or send in claims. After that, the companies don't have to pay claims to the doctor under the contract.
4. Insurance companies provide doctors' offices with long distance toll phone numbers that are constantly busy or never answered. The insurance company then staffs the phones with people of limited knowledge. Knowledgeable insurance company employees are hired to collect your premiums, while the less adept are hired to consider the doctors' claims. Net effect: money comes in to the insurance company faster than it runs out; hence, increased profits!
5. Insurance companies frequently refuse to state in writing whether a particular procedure is covered. Companies always defer to a "panel" who will make this determination merely by looking at a two-dimensional picture or written report AFTER the work has already been done on a living, breathing, three-dimensional patient.
6. Insurance-company decisions have injured and killed numerous Americans and the insurance companies cannot be sued because the politicians whom they support with campaign contributions wrote ERISA into law. ERISA makes it virtually impossible to sue an insurance company properly. It leaves the doctor in the middle, holding the bag for insurance (managed-care) company decisions.
7. Insurance companies put "gag" clauses in the doctors' contracts, forbidding doctors to say anything bad about an insurance company or its decisions that harm patients. Some states have passed laws banning these gag clauses.
8. Insurance companies just plain don't pay the doctors and the doctors then have to sue the companies. Remember Oxford Health Plan: Oxford got into serious trouble with New York courts and Wall Street after years of nonpayment to New York doctors and hospitals for billions of dollars while Oxford executives made off with tens of millions of dollars. Companies have attorneys on retainer and are experts at stalling any case. When the doctor wins, insurance companies appeal and drag it out further. Insurance companies like to throw cases into Federal Court where the doctors are not entitled to recoup their attorneys' fees. The doctor may win, but could collect less than the suit cost in attorneys' fees and legal costs for experts, etc. The stress of litigation and the doctors' time it consumes, eat into good patient care.
9. Another managed-care-company trick is to owe a doctor tens of thousands of dollars and not pay for a year or so. Then the managed-care company says to the doctor, "We cannot pay now. If you need the money badly now, you will have to take 50 cents on the dollar." Many doctors feel they must accept the offer rather than hire a lawyer and sue the big, rich, powerful insurance company. (See the probable result in number 8 above.)
10. Insurance companies may audit your doctor after years of service and arbitrarily, without any written guidelines, deny coverage for procedures that were performed and paid for. They can ask the doctor for all the monies back that have been paid for a certain procedure(s).

There are many more tricks used on unsuspecting doctors who are busy just trying to take care of patients and cover their overhead and provide for a family. Patients who are members of PPO's and HMO's may not want to know about the behavior of the insurance and managed-care-companies because they think it does not affect them. In a perfect world, this would be true. But in the real world, how managed "care" companies, which are really arms of big insurance companies in disguise, treat your doctors affects you whether you are under a plan or not! In a moment, we will explore those issues. But, first, let us digress to the basis for the problem.

Most doctors went into medicine with high ideals, motivated by a desire to help the injured and the sick. However, in the late '70's and '80's, the price for medical care rose out of proportion to the cost-of-living increase in the national economy. Some of this rise was based on doctors who felt their long hours and expensive education entitled them to drive Rolls Royces and Mercedes (or both), but much was due to the high price of high-quality, high-tech equipment and materials, as well as to the high cost to doctors of keeping up with new discoveries and new procedures. Doctors are notoriously poor at business management. High charges allowed them to avoid investment discipline and proper cost control, which is itself expensive (although as necessary as new instruments, a good staff, materials and continuing education). There was much fat in the system and it drained the American economy.

In reaction, the pendulum has swung to the opposite extreme, as it often does in American politics and economics. The politicians, who are now beholden to the insurance and managed-care companies for heavy campaign contributions, have seen to it that their contributors' coffers are filled at the expense of quality medical care of the patients' choice. People, perhaps even some you know, have been injured or have died as a direct result of the practices of managed-care and insurance companies. The question remains, for the politicians and the people who vote for them, "How much is a life worth?".

Some, but not all, doctors are frustrated that, while they studied on Friday and Saturday nights, other people partied and made money at regular jobs without going into tremendous debt to pay gigantic medical school tuitions. Some doctors are frustrated that, while they worked weekends and holidays, all night long at $4 per hour for a public hospital, risking exposure to AIDS and hepatitis, other people were at home with their families. Some doctors are frustrated that the average life span for a doctor is a decade or so less than that for the average American. These doctors may feel that the practice of medicine has even cost them their lives.

Other doctors, not including the author, may feel that, while they studied and worked hard for A's in high school and college, some insurance company workers and executives attained C's and D's. These doctors may feel that the present system is "the revenge of the D students"; the author does not feel that insurance people are not intelligent. They have certainly outfoxed the medical community. Some doctors may wonder why a corporate veil allows businessmen to contaminate children's drinking water and personally walk away from a lawsuit; these doctors wonder why physicians have personal legal liability with no veil to protect them. Other doctors wonder why medical school taught them only how to treat patients and not how to deal with a system of businessmen and lawyers out to snip their pockets.

The author actually expected medicine to be socialized by the time he finished medical school having little knowledge of the then-small "managed-care" system. His personal interest was in caring for people and wildlife, inventing things and publishing. Anything else is an unexpected gift. But this website author can sympathize with the feelings of these doctors discussed in the previous paragraphs.

Medical schools do not feel it is their place to educate doctors on how to make money. After all, is that the purpose of a physician? There is more than enough to learn about the body. Maybe doctors should be offered courses at university business schools as part of the curriculum, when they have time. Doctors are ill-prepared to sign the contracts that managed-care companies give them. Even with the help of their lawyers, doctors discover that managed-care-contract language is vague and easily changeable, not by the doctor, but by, and in favor of, the insurance (managed-care) company. Doctors run like cattle to sign the contracts, even against the advice of their attorneys, because they are afraid of losing their patients.

Once contracted (signed up), doctors may be in for rough time. The author knew one insurance company processor (personally) who told him that one of the largest managed-care companies told her to throw one out of three claims into the trash on a regular basis. Doctors simply cannot send every claim by certified-mail to these companies. Filing and storing the certified mail notices would cost thousands of dollars. The reader may be familiar with these practices from his/her own experience in dealing with the same companies or with Medicare and/or Social Security. Individual doctors who are not paid cannot take the companies to court because of contract restrictions and costs. Managed-care companies send frequent frivolous paperwork to doctors for "homework" in order to find a way to deny or to slow down paying a claim while "gumming" up the office. Dealing with enough of these companies requires a giant billing department or it will literally paralyze a doctor's office. Remember that a claim slowed down allows the insurance company to invest the unpaid money and make even more money. A claim not paid is free money in the stockholders' and insurance company executives' pockets.

Back to the point at hand. Without even considering the malpractice crisis of the early 2000's, the frustration that some doctors feel with managed-care plans, insurance companies and the system may unfortunately spill over onto their patients. Patients get caught in the middle because these doctors feel that the patients are somehow related to the "system." Inexpensive, rapid or no treatment may be given to HMO patients, as a result of the polices of the company in charge. It is certainly ironic that the manage-care system, intended to provide low-cost medical care to every citizen, has come to stand for poor-quality car for every member.

Patient knowledge is the one weapon that can counteract these potential problems. The author's advice is for patients to learn everything possible about the diseases or conditions with which they have been diagnosed, and their potential treatments, between visits to their doctors so that informed interplay (talk) will take place between doctor and patient. It probably does not hurt for patients to sympathize with the plight of the doctor who is tangled in the web of "managed care."