I-Team: Are insurance companies practicing medicine?

I-Team: Are insurance companies practicing medicine?

CAPE GIRARDEAU, MO (KFVS) - Brenda Brown of Cape Girardeau is a breast cancer survivor.

Her diagnosis came as a real shock, but so did the costs.

"My medical bills came to over a million dollars," said Brown.

Not everything was covered.

"There was one pill out there for me for treatment, Medicaid didn't cover it...my doctor did," said Brown.

She says Medicaid also denied some tests her doctor ordered.

"It made me mad, he's my doctor so what right does it give the government or the insurance company to tell him what I need," said Brown. "They don't have a medical diploma...he does."

That's one reason Dr. Michael Wulfers left his practice.

While he is the first in Cape Girardeau, Doctor Wulfers joins a growing number of doctors to start a direct primary care practice, or concierge medicine.

"I do not accept any insurance, no commercial insurance, Medicaid or Medicare," said Doctor Wulfers.

Instead, his patients pay a monthly fee of anywhere from $40 to $79 dollars.

"It's kind of like a gym membership," said Doctor Wulfers.

It covers unlimited visits to his office, and 24/7 access to Wulfers.

He said he often communicates with patients through e-mail, text or even facetime.

"I am really enjoying myself now, spending more time with my patients," he said.

Before, he said a great deal of frustration came with excessive documentation.

"I was spending 2-3 hours a night at home doing paperwork," said Dr. Wulfers.

He said it was mostly for the government, or the insurance companies, who sometimes affected how he treated patients.

We asked him if that meant they were practicing medicine.

"When they deny diagnostic treatment the physician wants, they come close," Wulfers said.

Wayne Meyer is a retired surgeon.

He now serves at the medical director for Anthem Blue Cross Blue Shield of Missouri.

He says insurance companies are not practicing medicine.

"We make reimbursement determinations," said Dr. Meyer. "We don't interfere with the doctor/patient relationship at all."

Dr. Meyer said his company follows evidence-based guidelines.

For example, if a doctor wants you to undergo a type of treatment that might be experimental, or not well studied, there is a decent chance it could get denied.

"We looked at it based on medical policies and guidelines," said Meyer. "It's not like we make decisions arbitrarily or off the top of our heads."

It's a multi-step process, and you and your doctor have several ways to state your case if you truly believe that treatment, medication or procedure is necessary.

"Overall there's a denial rate that goes into appeals in about 3 percent of all the thousands of cases," said Meyer.

"But, sometimes they make it so hard to obtain a test that they figure you'll just give up," said Dr. Wulfers.

Dr. Wulfers is not completely free from dealing with pre-certifications as there are times that there are things he cannot do in his office that his patients would have to do elsewhere.

He does suggest that if a patient chooses his practice, Independent MD, that they also carry a "catastrophic" insurance policy, and also have a Health Savings Account.

"But, I will say that about one-third of my patients are uninsured, they are the working poor and with my practice they can at least get their primary care," said Dr. Wulfers.

Wulfers said his practice isn't a brand new idea. In fact, he said it was first introduced in the 1990s.

"It's now increasing at a rate of 25 percent, there are about 4,000 like me in the United States," said Dr. Wulfers.

Brenda Brown is just thankful her doctor paid for the costly nausea medication she needed during her cancer care that wasn't covered.

"I wouldn't have made it, and I wouldn't have lived through it as I couldn't eat and couldn't keep nothing down," said Brown.

She still can't stomach the price tag.

"It was outrageous they wanted $3,000 for three pills," she said

The Medical Director at Anthem said that is probably the number one problem with healthcare today.

Dr. Wayne Meyer said don't paint the insurance companies as the bad guys.

His concern right now is the cost of prescription drugs.

"We have no price controls in the U.S.," said Meyer. "To pay for it, insurance companies have to increase premiums so everybody pays more."

To his point, according a Yahoo Finance analysis in 2012, insurance industry profits were at 4.5 percent.

Compare that to major drug manufactures, who had an average profit of 16.7 percent.

Copyright KFVS 2012. All rights reserved.