Commentary: The 800-Pound Ghost in Your Doctor’s Office

By Michael Gold

Every time you go to a doctor, you have an unwanted 800-pound ghost in the office, always injecting itself into every conversation about your treatment.

That ghost is, of course, your insurance company.

The doctor’s goal is to use his or her medical training to restore you to good health, while the insurance company, despite all their demonstrative protestations, seems to care primarily about profits, creating a fundamental tension.

That tension requires both the patient and the doctor to do a delicate dance to make sure the treatment you need to get better will be covered by your insurer.

The insurance company stands as the ultimate authority judging whether you can get the care you need.

The vast majority of Americans jealously guard their freedoms, but they also willingly allow countless restrictions on their ability to get decent health care by powerful, faceless private organizations that are rarely held accountable by government or anyone else.

I’m a retired teacher and I have relatively good health insurance. And yet, the conflict between the doctor and the insurance company is always there whenever I have a problem requiring treatment more serious than a prescription, physical therapy or vaccine.

For instance, I currently need minor dental surgery, or I’m going to lose some teeth. My insurance company is giving my dental surgeon and me a really hard time.

The surgeon submitted the pre-approval submission for the procedure.

The insurance company responded by sending me a letter stating: “A claim on the above referenced patient is delayed pending receipt of additional information…If we don’t receive it, we will have to deny the claim.”

I made an urgent call to the dentist to provide the information, which he did.

A week later, I got a second letter stating that the dentist did not use “a valid procedure code” in submitting the pre-approval for part of the procedure, so the company could not cover the claim.

I made a second, urgent phone call to the dentist’s office to make sure they used the correct code in submitting the pre-approval a second time.

Now, here I will make the jump to sheer speculation, but I confess it’s crossed my mind. I question whether the delay in approving the procedure is part of a deliberate strategy by the insurance company to slow down the processing of the ultimate payout to the dentist.

On a far more critical level, several years ago, while trying to shovel my car out from about two feet of snow that had piled up after a storm, so I could get to work, I experienced severe chest pain.

I called my doctor. He said get to the hospital, fast.

The emergency room personnel gave me nitroglycerine. The attending physician decided I needed to be admitted.

This created a dilemma many patients must face. If I stay in the hospital, will the insurance company cover it?

With up to 10 years of rigorous medical training, doctors have far more knowledge about your condition than you do. Should you disregard their judgment and possibly face a worsening of your health?

The hospital will require you to sign a waiver clearing them of liability if you decide to walk out. That’s an additional, powerful reason to trust the doctor’s conclusions.

But insurance companies contradict doctors’ judgments all the time, often after the fact.

On the doctor’s authority, I stayed in the hospital, took a stress test, got treated and was discharged two days later.

Weeks after that, the insurance company sent me a letter denying the claim, because in their words, my stay was not medically necessary. How could they possibly know?

The insurer can come up with all kinds of jargon to justify their decisions, that ordinary people like me usually don’t understand.

Thankfully, after this scare, the hospital and insurance company worked it out and I didn’t have to pay much for the cost of my stay. But there are many other people who don’t enjoy that experience.

It seems to come down to one thing. The insurance companies don’t seem as interested as your doctor in helping you heal.

Not incidentally, CEO pay at a health insurance company is extremely rewarding. The CEO of my hospital insurer received $17 million in compensation in 2020.

The CEO of my dental insurer received $13 million in compensation in 2019 and $79 million in 2020.

This system is terribly broken.

Pleasantville resident Michael Gold has written op-ed articles for The New York Daily News, the Albany Times-Union and other newspapers.