Health insurers have been rating physicians and physician practices over the years. In some of those ratings, you find some really bland things, as well as some scores that always incite heated and passionate reaction.

It took physicians — through the American Medical Association (AMA) — quite a few years to get hip to the idea of rating the insurance industry, but the tables have now been turned. The outcome: the expected over-inflated image of health insurers saying the ratings aren’t fair, as well as brutal honesty, it seems, about the timeliness of payments made by the health insurers.

Sure, the health insurers fired back a few volleys, saying that in most instances where physicians weren’t paid quickly, or, for that matter, according to the contractual terms, the health insurers said, in essence, "Not everything is our fault. The doctors make mistakes when submitted claims, too!"

Is the insurance industry being honest about physicians making mistakes during billing. Absolutely. In fact, over a decade ago, I worked for a short time for CIGNA, handling calls and claims for United Airlines. During that time, which was more of an evolutionary period of my life during a bitter divorce, I saw claims from physicians asking for reimbursement for office tissues!

Yes, the world of insurance is interesting, at best.

The insurance and medical rating guide I’d love to see is one assembled by several hundred American health care consumers from around the U.S. The focus of that report would be on the approval or denial of claims submitted by physicians, as well as outrageous insurance industry policies, such as getting pre-authorization for an emergency dental treatment or for a walker or cane. Then there’s the classic denial of services from health insurance companies for "above usual and customary" and "not medically necessary."

First, does it matter if a physician is charging "above the usual and customary" fee that other physicians in the same area are charging? No. In fact, physicians, like any other professional, ought charge based on experience, procedure, training, and whatever other criteria the physician or group practice decides upon.

As for the "not medically necessary" denial, it’s a hoot. Often times the decision is rendered by a nurse who does a quick review of earlier claims submitted on the patient, a review of current literature, and then gives a yes or no. Sorry, but that doesn’t cut it in my book. If I need a procedure, it’s my physician, not the insurance company, that should be making the decision. Sadly, because the insurance company gets to say they hold the purse strings, though it’s really the person insured who is holding the purse strings, the insurance company gets to be a bully. More people need to push the envelope on this, challenging health insurance companies in court over the denials, or, at the very least, pushing appeals all the way to their state department of insurance, to the insurance commissioner, and then, if need be, to elected officials, encouraging a law be enacted to mandate coverage for XYZ procedure. Sure, the insurance lobby would cry and scream and fight all the way to the moon over something like that, but who cares?

More information about the [1] report by the AMA may be found on the [2] NBC10 site, including a PDF version of the full report.