Insurance companies 'undermine' health care

Doctors complain they are forced to delay treating patients while they wait for firms to grudgingly approve payment.

ABU DHABI // A lack of trust between insurance companies and medical professionals is eroding care and undermining treatment for some patients, doctors have said. Insurers must approve the cost of medical treatments before payments are approved. Although the industry standard is 24 hours for standard approval, and no approval is needed for emergency treatment, many doctors say it can take much longer. Some also say the insurance companies, at times, interfere with clinical decisions.

"The entire healthcare system is undermined by a lot of distrust," said Dr Klaus Kallmayer, the chairman of the German Heart Centre Bremen in Dubai. "The problem is that our patient comes in and we can put our hands on his chest to see if his heart is beating and look into his eyes - but that is about all the insurance company will pay for. It does not matter whether the attending physician is an outstanding specialist with excellent credentials or not.

"The procedures that are ordered are vetted by the insurance company doctors who as a rule have very little or no clinical experience.' The delay in care while doctors wait for approval from the insurance company can be dangerous in some circumstances. In such situations the doctors will often treat patients and hope that the insurance company will pay, he said. "When we get the approval it's fine - but if we don't?"

He said many clinics quietly paid for treatments insurance companies reject, but that legally the patient was obliged to pay. Mr Shankar Chellaram, from Goodwill Insurance Brokers in Dubai, said the purpose of insurance was to provide a safety net for people in situations where they might otherwise become destitute, but this only worked if they were able to stick to a viable business model. "The concept of insurance works because the outflow has to be less than the inflow. If the outflow is more than the inflow then the insurance company would have to close down, so it makes sense for them to have intelligent checks and balances."

He said that to do this, many companies had a maximum limit on what they were willing to spend on their clients. Although insurance companies do not dictate how a doctor will treat a patient, they do dictate whether the procedure will be paid for. "The brokers will call me and ask me not to prescribe a certain medicine because they have not budgeted for it and the patient has crossed his limit," said Dr Dillan Shetty, an ear, nose and throat consultant at Al Amin Medical Centre in Abu Dhabi.

He said the basic insurance policy of many of his patients limited their available medical treatment. Often compassion will lead the doctors to give those patients free or discounted treatment and whatever free medicine samples are available. "There are many instances when patients have been running from pillar to post for emergency medical care and it has taken two or three days to get treatment."

The insurance companies say, however, that healthcare providers do not always comply with proper procedures, adding time to the claim. Dr Kallmayer called on the insurers to give appropriately vetted hospitals pre-approval for funding based on clinical decisions. He said contracts could be closely vetted and withdrawn if necessary. This would provide the necessary checks and balances. "They have all sorts of doctors in contracts with them. They say, we have looked at you, we have inspected you and your facility but we don't trust you nevertheless. I think once they've inspected an institution and made sure the doctor is qualified and has a good reputation then they have to accept what the doctor does.

"If he deviates wildly from what is generally done then they might look into this, but otherwise they should pay what he thinks is right for the patient. Otherwise it doesn't function." Dr Jad Aoun, the chief medical officer of Daman, the national insurance company said: "The providers do not follow the rules. "They wait until the last minute and start rushing us. When we get a cold case, we don't rush to do it. We leave priority to the emergency cases." He said that often the hospital will call to complain and hope that because the patient is standing in front of them they will speed up the process.

Sometimes the doctor has not included all of the relevant data and the insurance company needs more information before it can make a decision, he said. "Some of the doctors are bothered that we are asking for so much information and say that we should be approving blindly. "If a doctor knows that his patient has insurance the way he writes his prescription or does his investigation to reach the diagnosis is different. It loosens what is necessary and the bill gets bigger.

"We are the guardians of the money that is being given to us to cover the nationals, so we cannot just accept the paper signed by the doctor." He said the second opinion that the insurance companies sometimes demanded could provide an alternative for patients who might have not been aware of what other options were available. "I should pay the real price for the real disease, and it's not about cutting costs. Some cases in medicine are not black and white."