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Doctoring Without Health Insurance

After 20 years in practice, Dr. Manya Helman recently decided not to accept insurance payments anymore. Helman runs a small clinic in a Salem office building.

“I’m actually enjoying practicing medicine for the first time since I started practice,” said Helman.

She says she can take as much time as she wants with a patient and her business  doesn’t have to deal with all the paperwork.

Dr. Manya Helman talks to patient Valerie Peterson about her painful wrist.

Kristian Foden-Vencil / OPB

Doctors often grumble about health insurance companies. The aggravation spent negotiating payments they say, costs money and takes time away from patients. Now some Oregon doctors are opting out of Medicare and refusing to bill health insurance companies, leaving patients to deal with the paperwork themselves.

So now, instead of handing over their insurance details when they arrive, Helman’s patients pay up front. Helman charges $85 for a regular check-up,  $30 for a vitamin injection, and so on. Patients are given a receipt and it’s up to them to get reimbursed by their insurance company.

Patient John Tackett appreciates the change.

“She can tell me how much it’s going to cost. How much the labs are going to be, etcetera. it’s pretty up-front,” says Tackett.

Tackett actually has health insurance — through the Veterans Administration.

But for him, a doctor’s visit the the VA means a 100 mile round trip to Portland. So he uses his health insurance like his car insurance.

For a routine doctor’s visit he pays out of pocket and doesn’t seek reimbursement, just as he would pay out of pocket to change the oil in his car.

But if he gets really sick and needs to be hospitalized, he’ll go to the Veterans Administration — just as he’d file a claim with his car insurance to pay for a big smash-up.

He says knowing what everything costs is a relief, unlike his previous insurance bills. 

“Because you never know, when you open up the mailing, that you’re going to be on the hook for several hundred dollars or whether they’re going to cover it. You come here, it’s going to be cut rate. You know in advance what it’s going to cost, you pay it and you get good service,” says Tacket. 

Doctor Helman says she can afford to have lower prices because she doesn’t need a big billing staff. In fact, she decided to forego insurance when faced with the decision to hire yet another person to deal with all the insurance codes and paperwork.

Inside an examination room, Doctor Helman examines another patient. Valerie Peterson is here for a painful wrist.  Helman explains her medical options:

“It costs maybe 10 cents and the patch cost maybe $5 or $7 dollars. So, big bucks. But I have two studies showing benefits for wrists. It’s a patch,” says Helman. 

Peterson says it’s a relief to be told how much medicines cost.

“The options are there and open to me to know what is available to me in my financial situation,” says Peterson.

Peterson works in a laboratory in Salem, so she has health insurance.

But she pays for visits up front, then takes the paperwork home to get reimbursed. And she says that is inconvenient. 

“It is a pain in the neck. Ha ha. It is. And it’s time consuming,” says Peterson.

But she stays with Doctor Helman.  

“I still chose to come here without the insurance, even though it’s a negative effect on me financially, because she listens and I understand the not accepting the insurance because she’s allowed to treat patients the way she sees,” says Peterson.  

The new system has also changed life for Doctor Helman’s staff as well. Kim Stadli, her medical assistant, says she’s relieved not to have to deal with the endless calls about convoluted insurance codes, and the angry patients.

“Most of the patients were very argumentative about you know, I don’t understand why this wasn’t billed this way, and how come they didn’t take more money off, and why do I still owe this much money. It was just a big fight. Mostly with the patients, which I don’t like to fight.  And now, we don’t have that fight. And patients are like, okay, how much do I owe?” says Stadli.

Kristian: “And they write out a check.”

Kim Stadli: “And they write out a check.”

Across the state in Coos Bay, Kathleen Brown is a dermatologist. She foreswore insurance last summer. She concedes she lost some patients and she’s had trouble with insurance companies like Regence BlueCross BlueShield of Oregon. ODS was particularly difficult she says.

“They’ve told their members to go elsewhere. And I’ve tried talking to them on the phone. They don’t care that the rates are lower, they just want it done a certain way,” says Brown. 

ODS Health spokesman Jonathan Nicholas says the standardized system for coding and billing is part of a simplification process that helps to make healthcare more affordable. And while he says he “deeply respects” Brown’s right to practice medicine as she chooses, ODS needs a code telling what the claim is for in order to pay claims for her patients.

Scott Burton of Regence BlueCross BlueShield of Oregon says Brown uses ‘time based billing’ instead of those codes.

Scott Burton: “To reimburse a provider, we’re required to bill by prescribed codes, established by the American Medical Association. These codes allow similar services to be compared one another, from doctor to doctor, apples to apples. So if a doctor like Doctor Brown choses to bill without using these codes, insurers have no way to reimburse for these services.”

While Regence’s requires those codes, its parent company just started up another company in Portland that doesn’t use codes. It’s called ‘Sprig Health’ and it connects patients looking for less expensive care with doctors who are looking for more customers.

It works a little like an on-line travel service. But instead of putting in: three nights; Las Vagas; New Year’s Eve; — patients put in the procedure they need; the time they’d like the appointment; and the location. They can then choose from the options that appear.

Sprig president Chris Gorriaran says the service is growing quickly.

“We have been pleasantly surprised at the rapid response of doctors coming on our site. We have 75 providers on the Sprig site today. And we hope to be at 120 by the end of December. The prices we’re seeing on the site are 50 to 75 percent below a standard price that you would see for say an insured customer,” Gorriaran says.

It’s hard to tell how many doctors are no longer dealing with insurance companies. But the U.S.  ‘Centers for Medicare and Medicaid Services’ keeps a list of doctors who’ve opted out of Medicare. In Oregon about 200 doctors are on that list. Across the country the number is in the tens of thousands.

So while a large majority of doctors still bill through insurance companies, it’s clear some are forging a new way.

Sources in this story came to us via our Public Insight Network.

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This story is part of a project on health care in the states, a partnership of OPB, NPR and Kaiser Health News.

Kaiser Health News is a nonprofit news service covering health policy and politics. It is an editorially-independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.