Interview with Todd Coulter MD
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TOPIC - HEALTH INSURANCE
Sorry, I don't accept insurance!
AO/Beck: Good morning Dr Coulter. It is a pleasure to meet you. I should start by telling the readers that you're a physician. If you don't mind, before we get to insurance issues, let's start with a little bit of information regarding your professional history.
Coulter: Absolutely. I did my undergraduate work at Granell College in Iowa class of '86. I went to medical school at the University of Illinois Medical School in Chicago and I graduated in the class of 1992. I was at the University of Illinois/Michael Reese Internal Medicine Training Program from 1992 to1995.
AO/Beck: And then you started your own practice in Mississippi?
Coulter: Yes, I came to Mississippi July, 1995.
AO/Beck: All right. So you've been in private practice now for about eight years?
Coulter: Yes. I came down here well healed. The hospital system recruited me from Chicago to open a private practice in this less populated area of Mississippi. They paid off my school loans and they gave me a guarantee of $140,000 a year for two years. All of this information is of course public record, and I don't mind sharing it.
AO/Beck: Thanks, I think the details are important and if you're comfortable expressing them, let's go with it! Please continue.
Coulter: When we really started getting busy in the private practice the paperflow and documentation problems were a nightmare! Delays on payments, denied reimbursements and filing and refiling with insurers. Patients often said things like, Well doctor, my insurance company paid you $35, and you say I owe you another $21 but I think you should file the insurance again.
Patients didn't want to assume responsibility for their own healthcare or the cost of their healthcare, and I don't blame them -- that's why they have insurance in the first place!
AO/Beck: I totally understand. From the patient's view, they're already paying way too much for their health insurance, and they're paying it from every paycheck, and if you're a provider in their network, they don't really wanna have to pay you too!
Coulter: The insurance companies deny, delay and devalue our services as professionals. Patients have few alternatives and they cannot afford, and do not want, to assume responsibility for their health issues, it all becomes exasperating.
AO/Beck: Absolutely. Been there, done that, got the insurance ID card and the EOB (explanation of benefits)!
Coulter: We decided we had to get out of the insurance company death spiral. That decision came about because we had to pay the bills too. I started moonlighting at one of the local urgent care facilities. Those guys were paying me up to $120 an hour. I was making $1200 a day - that's a lot of money! I was making more money doing walk-in clinic and taking care of basic medical problems, then I was at my own internal medicine practice. And Doug, that's when I learned -- they didn't need more chiefs, they needed more Indians! I decided to be an Indian. Yes, I'm trained in internal medicine and I've done all that kind of stuff, but you know, a year and a half ago we had $70,000 in accounts receivable and people did not want to pay their balance of $38. Of course it puts all of us in healthcare in a horrible position because we're the doctors and we don't want to be seen as money grubbing individuals, we want to heal and help, but again, we have to pay our bills too!
AO/Beck: It's amazing how HMOs, PPOs, Medicare, Medicaid and other insurers actually increase the cost of health care. When professionals are receiving 30 or 40 or 50 percent of their fees, and they cannot back bill the balance to the patient, and they must accept assignment the stage is not set for cost-cutting. Rather, creative billing and a lack of quality health care become the trends.
Obviously as a consumer, you cannot tell your health insurance company you've decided that your usual and customary payment will be 45 dollars for your family coverage this month, and they'll have to accept that and they cannot bill you or your employer for the balance - but that is exactly what the insurance companies to do us! We are told by the insurance companies how much they have decided to pay us, and by the way the check will be there in 90 to 180 days, and we have no alternatives. I cannot imagine any other business staying in business under those conditions!
Coulter: Yes, well I think you're exactly right and that's why we decided to get out. We saw a number of people who were willing to pay cash up front. We came up with one $40 fee. It was based on the cost of doing and staying in business, and noting what a reasonable fee would be, for most reasonable people.
AO/Beck: If you drive a van or sport utility vehicle, it's going to be about $40 to fill it up. So realistically, an office visit to a doctor for $40 is not outrageous.
Coulter: $40 is not expensive at all. And by the way, most folks with insurance have to pay 10 to 20 dollars for a co-pay anyway.
AO/Beck: A few days ago I had a plumber come out to my house. It was $120 for the half hour labor, the visit and the part.
Coulter: And when he submitted the bill to you for $120, he didn't have to discount it based on a pre-existing contract, and he didn't have to dictate or write what he did, he didn't have to go back and say this is allowable, and he didn't have to file the paperwork for you and pay the administrative help, and then wait 90 days to get paid. I'll bet you didn't tell him this is the allowable amount and this is the discount amount, and I'm only going to pay you this much because I have a co-pay!
AO/Beck: Exactly. I wrote the check for $120.
Coulter: No financial hopscotch. Obtain the services, get the bill, make the payment -- that method works for everyone. Without accepting insurance, we were able to cut the administrative costs dramatically. I saw 36 people in my clinic last Monday and I collected $1440. Cash on the barrelhead. I'm able to pay my bills and run an efficient business.
AO/Beck: What happens when the patient walks in the door and they say Doctor, I have Medicare. How do you handle that?
Coulter: I am a Medicare participant and as of this moment, I have not yet opted out of Medicare. I think the government has tried to fix the Medicare problem. So for me Medicare participation is like a loss leader. I go ahead and do it for good community relations.
AO/Beck: And indeed, Medicare is what many people depend on for their health care.
Coulter: I'm also a Medicaid participant, but I don't take Medicaid. I tell people up front. If you have Medicaid secondary to Medicare, that's fine. But Medicaid by itself - sorry. I just cannot afford to do that. Interestingly, a large percentage of our patients, probably some 70% of them actually have insurance. But they come in and they'll say, I'll pay Dr. Coulter $40 rather then screw around.
AO/Beck: If somebody has insurance, will you file the claim for them, or do you instruct them on how to do that?
Coulter: I instruct them how to do it. I say, Look at the back of your insurance card. Call that phone number and ask them to send you the form that you need to fill out. I will provide you with the diagnosis, the diagnosis code, and the appropriate level of E&M billing if that's necessary. You would think I'd get lots of requests for that type of information, but in reality, when the patients see what they have to go through, most people say it's not worth the bother. They don't even file! That's what usually happens.
AO/Beck: How do you think this is going to impact commercial and private insurance in years to come? If this kicks in as a major trend across the USA and people start to say The heck with it, I don't need to be paying $500 a month for healthcare because I don't go to the physician ten times per month. Do you think maybe we'll see a time a few years from now when people really just purchase catastrophic or major medical insurance?
Coulter: Well yes! I agree with you, not only are you going to see that happen, but you're going to have doctors like me who tell patients You're paying $485 a month for a family of four for health insurance and you've only gone to the doctor twice in the last five years. Who do you think is making all the money folks?
AO/Beck: Have any of your colleagues called you and said you must be crazy?
Coulter: Yes, they have. I've certainly had local doctors who've said it. But then, some of the guys who've had an opportunity to sit down and talk with me have said, Todd, you're doing what the rest of us are afraid to do.
AO/Beck: That's right. I think it would be a scary thing to convert over to not accepting insurance. That is, the transition would be scary, but the outcome would be wonderful!
Coulter: Yes. It really is. I tell the other doctors, I don't live in a mansion and I don't have a 50 foot boat. But you know what I've got? I've got perfect cash flow. I run basically a retail business as a physician. If people don't walk through the door, I don't make any money. But guess what? People do walk through the door and they spend money. Many of our colleagues are trying to come up with innovative ways of getting money from people. Some want to charge people for missed appointments and they want to charge people for telephone conversations. I tell them, Get real. Doctors and health care providers are afraid to go after the people who owe them money. They're afraid to sue the guy who owes them $1000 but yet they're going to charge some little old lady 50 cents for every minute of talk time! Give me a break. That's not going to happen.
AO/Beck: With specific regard to hearing aids, many insurance companies don't provide them at all. There are some insurers that will only pay for one hearing aid (imagine if they paid for one contact lens or a monocle, or one vessel coronary artery bypass) and they want the least expensive analog technology! Of course, the new technology (multiple programs, multi-channel, digital, directional, noise reduction etc) works extremely well, but the bottom of the barrel stuff is not something you and I would wear - yet that's what the insurance companies want to pay for, so they can market their contract as providing hearing aids.
Coulter: I am not an otolaryngologist or an audiologist, but I know from my practice, patients need the state of the art equipment, hearing aids, medicines and surgeries. You cannot take care of people maximally using outdated technology and knowledge! If you have hearing loss, you need to invest the money to get the good products. If the audiologist tries to fit technology based on a 1957 AM radio in your hearing aid, you're going to notice that the sound quality is not what you wanted! The reason computers have replaced typewriters, and CDs have replaced 8 tracks, is that digital technology works and it makes an enormous difference! Doug, to solve the health insurance issues in the USA, we have to empower people to make the best choices. We have to emancipate them from their entanglement. You know that most of our patients feel entitled, yet they are subservient to their insurance companies. They believe they paid this amount of money, so they could get that service or product, but what they find out is their insurance company pulls the rug out from under them. The insurance company says, Yes, you can have a hearing aid, but you can only have one. And guess what? We're only going to pay $350, and by the way, you have to go where we tell you, and by the way, you have to pay for the rest of it! It's crazy.
AO/Beck: Thanks so much for your time today, Dr. Coulter. You have an amazing and eye-opening perspective on all of this and I think this interview may serve as a catalyst for some consumers, patients and professionals - and hopefully for some insurance companies too!
Coulter: Thank you too Dr Beck. It has been a lot of fun and I appreciate the opportunity to tell my story. I've got more doctors around the country who call me and say, Hey listen, can you tell me how this is going ? I tell them it's hard work, motivation and personality. We each have to decide not to be a slave any more. Once you do that, you're golden!
AO/Beck: Thanks so much Dr. Coulter!
AO/Beck: Good morning Dr Coulter. It is a pleasure to meet you. I should start by telling the readers that you're a physician. If you don't mind, before we get to insurance issues, let's start with a little bit of information regarding your professional history.
Coulter: Absolutely. I did my undergraduate work at Granell College in Iowa class of '86. I went to medical school at the University of Illinois Medical School in Chicago and I graduated in the class of 1992. I was at the University of Illinois/Michael Reese Internal Medicine Training Program from 1992 to1995.
AO/Beck: And then you started your own practice in Mississippi?
Coulter: Yes, I came to Mississippi July, 1995.
AO/Beck: All right. So you've been in private practice now for about eight years?
Coulter: Yes. I came down here well healed. The hospital system recruited me from Chicago to open a private practice in this less populated area of Mississippi. They paid off my school loans and they gave me a guarantee of $140,000 a year for two years. All of this information is of course public record, and I don't mind sharing it.
AO/Beck: Thanks, I think the details are important and if you're comfortable expressing them, let's go with it! Please continue.
Coulter: When we really started getting busy in the private practice the paperflow and documentation problems were a nightmare! Delays on payments, denied reimbursements and filing and refiling with insurers. Patients often said things like, Well doctor, my insurance company paid you $35, and you say I owe you another $21 but I think you should file the insurance again.
Patients didn't want to assume responsibility for their own healthcare or the cost of their healthcare, and I don't blame them -- that's why they have insurance in the first place!
AO/Beck: I totally understand. From the patient's view, they're already paying way too much for their health insurance, and they're paying it from every paycheck, and if you're a provider in their network, they don't really wanna have to pay you too!
Coulter: The insurance companies deny, delay and devalue our services as professionals. Patients have few alternatives and they cannot afford, and do not want, to assume responsibility for their health issues, it all becomes exasperating.
AO/Beck: Absolutely. Been there, done that, got the insurance ID card and the EOB (explanation of benefits)!
Coulter: We decided we had to get out of the insurance company death spiral. That decision came about because we had to pay the bills too. I started moonlighting at one of the local urgent care facilities. Those guys were paying me up to $120 an hour. I was making $1200 a day - that's a lot of money! I was making more money doing walk-in clinic and taking care of basic medical problems, then I was at my own internal medicine practice. And Doug, that's when I learned -- they didn't need more chiefs, they needed more Indians! I decided to be an Indian. Yes, I'm trained in internal medicine and I've done all that kind of stuff, but you know, a year and a half ago we had $70,000 in accounts receivable and people did not want to pay their balance of $38. Of course it puts all of us in healthcare in a horrible position because we're the doctors and we don't want to be seen as money grubbing individuals, we want to heal and help, but again, we have to pay our bills too!
AO/Beck: It's amazing how HMOs, PPOs, Medicare, Medicaid and other insurers actually increase the cost of health care. When professionals are receiving 30 or 40 or 50 percent of their fees, and they cannot back bill the balance to the patient, and they must accept assignment the stage is not set for cost-cutting. Rather, creative billing and a lack of quality health care become the trends.
Obviously as a consumer, you cannot tell your health insurance company you've decided that your usual and customary payment will be 45 dollars for your family coverage this month, and they'll have to accept that and they cannot bill you or your employer for the balance - but that is exactly what the insurance companies to do us! We are told by the insurance companies how much they have decided to pay us, and by the way the check will be there in 90 to 180 days, and we have no alternatives. I cannot imagine any other business staying in business under those conditions!
Coulter: Yes, well I think you're exactly right and that's why we decided to get out. We saw a number of people who were willing to pay cash up front. We came up with one $40 fee. It was based on the cost of doing and staying in business, and noting what a reasonable fee would be, for most reasonable people.
AO/Beck: If you drive a van or sport utility vehicle, it's going to be about $40 to fill it up. So realistically, an office visit to a doctor for $40 is not outrageous.
Coulter: $40 is not expensive at all. And by the way, most folks with insurance have to pay 10 to 20 dollars for a co-pay anyway.
AO/Beck: A few days ago I had a plumber come out to my house. It was $120 for the half hour labor, the visit and the part.
Coulter: And when he submitted the bill to you for $120, he didn't have to discount it based on a pre-existing contract, and he didn't have to dictate or write what he did, he didn't have to go back and say this is allowable, and he didn't have to file the paperwork for you and pay the administrative help, and then wait 90 days to get paid. I'll bet you didn't tell him this is the allowable amount and this is the discount amount, and I'm only going to pay you this much because I have a co-pay!
AO/Beck: Exactly. I wrote the check for $120.
Coulter: No financial hopscotch. Obtain the services, get the bill, make the payment -- that method works for everyone. Without accepting insurance, we were able to cut the administrative costs dramatically. I saw 36 people in my clinic last Monday and I collected $1440. Cash on the barrelhead. I'm able to pay my bills and run an efficient business.
AO/Beck: What happens when the patient walks in the door and they say Doctor, I have Medicare. How do you handle that?
Coulter: I am a Medicare participant and as of this moment, I have not yet opted out of Medicare. I think the government has tried to fix the Medicare problem. So for me Medicare participation is like a loss leader. I go ahead and do it for good community relations.
AO/Beck: And indeed, Medicare is what many people depend on for their health care.
Coulter: I'm also a Medicaid participant, but I don't take Medicaid. I tell people up front. If you have Medicaid secondary to Medicare, that's fine. But Medicaid by itself - sorry. I just cannot afford to do that. Interestingly, a large percentage of our patients, probably some 70% of them actually have insurance. But they come in and they'll say, I'll pay Dr. Coulter $40 rather then screw around.
AO/Beck: If somebody has insurance, will you file the claim for them, or do you instruct them on how to do that?
Coulter: I instruct them how to do it. I say, Look at the back of your insurance card. Call that phone number and ask them to send you the form that you need to fill out. I will provide you with the diagnosis, the diagnosis code, and the appropriate level of E&M billing if that's necessary. You would think I'd get lots of requests for that type of information, but in reality, when the patients see what they have to go through, most people say it's not worth the bother. They don't even file! That's what usually happens.
AO/Beck: How do you think this is going to impact commercial and private insurance in years to come? If this kicks in as a major trend across the USA and people start to say The heck with it, I don't need to be paying $500 a month for healthcare because I don't go to the physician ten times per month. Do you think maybe we'll see a time a few years from now when people really just purchase catastrophic or major medical insurance?
Coulter: Well yes! I agree with you, not only are you going to see that happen, but you're going to have doctors like me who tell patients You're paying $485 a month for a family of four for health insurance and you've only gone to the doctor twice in the last five years. Who do you think is making all the money folks?
AO/Beck: Have any of your colleagues called you and said you must be crazy?
Coulter: Yes, they have. I've certainly had local doctors who've said it. But then, some of the guys who've had an opportunity to sit down and talk with me have said, Todd, you're doing what the rest of us are afraid to do.
AO/Beck: That's right. I think it would be a scary thing to convert over to not accepting insurance. That is, the transition would be scary, but the outcome would be wonderful!
Coulter: Yes. It really is. I tell the other doctors, I don't live in a mansion and I don't have a 50 foot boat. But you know what I've got? I've got perfect cash flow. I run basically a retail business as a physician. If people don't walk through the door, I don't make any money. But guess what? People do walk through the door and they spend money. Many of our colleagues are trying to come up with innovative ways of getting money from people. Some want to charge people for missed appointments and they want to charge people for telephone conversations. I tell them, Get real. Doctors and health care providers are afraid to go after the people who owe them money. They're afraid to sue the guy who owes them $1000 but yet they're going to charge some little old lady 50 cents for every minute of talk time! Give me a break. That's not going to happen.
AO/Beck: With specific regard to hearing aids, many insurance companies don't provide them at all. There are some insurers that will only pay for one hearing aid (imagine if they paid for one contact lens or a monocle, or one vessel coronary artery bypass) and they want the least expensive analog technology! Of course, the new technology (multiple programs, multi-channel, digital, directional, noise reduction etc) works extremely well, but the bottom of the barrel stuff is not something you and I would wear - yet that's what the insurance companies want to pay for, so they can market their contract as providing hearing aids.
Coulter: I am not an otolaryngologist or an audiologist, but I know from my practice, patients need the state of the art equipment, hearing aids, medicines and surgeries. You cannot take care of people maximally using outdated technology and knowledge! If you have hearing loss, you need to invest the money to get the good products. If the audiologist tries to fit technology based on a 1957 AM radio in your hearing aid, you're going to notice that the sound quality is not what you wanted! The reason computers have replaced typewriters, and CDs have replaced 8 tracks, is that digital technology works and it makes an enormous difference! Doug, to solve the health insurance issues in the USA, we have to empower people to make the best choices. We have to emancipate them from their entanglement. You know that most of our patients feel entitled, yet they are subservient to their insurance companies. They believe they paid this amount of money, so they could get that service or product, but what they find out is their insurance company pulls the rug out from under them. The insurance company says, Yes, you can have a hearing aid, but you can only have one. And guess what? We're only going to pay $350, and by the way, you have to go where we tell you, and by the way, you have to pay for the rest of it! It's crazy.
AO/Beck: Thanks so much for your time today, Dr. Coulter. You have an amazing and eye-opening perspective on all of this and I think this interview may serve as a catalyst for some consumers, patients and professionals - and hopefully for some insurance companies too!
Coulter: Thank you too Dr Beck. It has been a lot of fun and I appreciate the opportunity to tell my story. I've got more doctors around the country who call me and say, Hey listen, can you tell me how this is going ? I tell them it's hard work, motivation and personality. We each have to decide not to be a slave any more. Once you do that, you're golden!
AO/Beck: Thanks so much Dr. Coulter!
