Wednesday, October 9, 2013

Out of Network !?!? (Part 2)




In my last blog I discussed being out of network from both the patient and provider's perspective. I failed to present one other perspective. I should have included the perspective of insurance companies.

Insurance companies may not like what I have to say, but facts are facts.

Insurance companies, like any other business are in business to make money. How do insurance companies make money? Well, they make their money in the premiums they receive from employers and the insured. They keep this money by paying out as little as possible in insurance claims. So in a nut shell, to make money, they must have as many people paying premiums as possible but must also deny or lower as many claims as possible.


There is a major conflict of interest. They are in the business of helping maintain the health of their clients, but in order for them to be profitable they must deny services or dramatically reduce the covered benefit to be profitable.

This is true regardless of the type of insurance. It could be fire insurance, life insurance, auto insurance and countless other types of insurance. The same business model exists. Bring in as much money as possible and pay out as little as possible.

You may ask how I can make these allegations against insurance companies. Well, you may have some stories of your own where you may have felt that you've been mislead or given the run around by an insurance company.

We are in the trenches where we see this activity everyday. They put up as many road blocks as possible for my patients (and for me) as they possibly can. I can't even say how many times an insurance company has sent a denial back to us stating that they need x-rays. But on the returned claim, you see where the x-ray was ripped off of the claim as evidenced by the ripped paper from where it was stapled.

Okay, I guess I've vented enough on insurance companies.

Do your own research on your insurance. If you cannot get the care you need and deserve, you may have to be prepared to get as active in the process as possible. You may need to fight them on occasion. There are government agencies where you can report insurance abuse. In Illinois, there is the Illinois Department of Insurance. You may have to figure out who to file with in your own state.


Dr. Cisneros maintains a practice in Freeburg and Columbia, IL. Both are in the Greater St Louis, MO area. For more information on a wide variety of subjects, please visit www.advanced-smiles.com

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