Secret Shopper

Let’s pretend that you are getting paid at some job. Maybe in a store in a mall. A secret shopper comes in to see if you can sell something to them. You get paid whether they buy or not. The secret shopper gets paid no matter what happens. For you, it is just a game and everyone comes out with money in their pocket.

I just got another message from an insurance company. They are announcing the continuation of their secret shopper program. Another thing to have to read. Another wasted amount of professional time to deal with some bs regulation. From a company that cheats its providers out of fees needed for the providers to pay overhead. You think I am kidding? Not at all.

In the mall store situation everyone gets money in their pocket during the secret shopper charade.

But in the medical insurance world, the policy wonks and the insurance executives make up rules, getting paid all the way to the bank. The providers that they make up the rules for? It is all just a giant waste of time. They don’t get paid and yet have to take their valuable time to talk on the phone to someone who is just making a fake call, to make a fake appointment for a situation that is a lie. The caller doesn’t really need an emergent appointment or even an less urgent appointment. They are getting paid to essentially hassle the provider and their staff. They waste valuable clinical time and take money out of the pocket of the provider.

Do the insurance carriers care? Is it really necessary? No. Is it just a way for the insurance company “compliant officer” to justify their high salary? More likely.

Nowhere else in the commercial world does this happen.

Well, the insurance carriers are now making huge amounts of money for “administration” of medical treatment. The CEOs and the bean counters make huge salaries. Where do the funds come from? From the payments to providers. The people who have spent time and money to get their expertise to help patients. The people who are actually providing the services. The administrators — just middle people taking a huge cut out of the money that should be going to real patient care.

Unlike the administrators, CEOs, “compliance officers,” government regulators, most providers like acupuncturists and chiropractors and massage therapists don’t have jobs. They don’t get a salary.
They only get paid if they see a patient. If they are lucky, they have an all cash practice so they don’t have to deal with the insurance payment system. Because if they deal with the cumbersome and wasteful insurance administration systems, even if legitimate services are provided, the insurance company decides whether they will get paid or not. And the payments are now, in 90% of cases, 50 -80% less than they were 20 years ago.

Then we get this new rule that insurance companies impose on providers, who are not paid enough to cover overhead and still make a middle class income. Seriously, I hear about the struggles daily for almost all practitioners.

Once again, the provider squeezing insurance middle men are warning again about the “secret shoppers” who will call. The “secret shopper” model is used in which the surveyor calls the practitioner’s office as a potential patient to see how soon he/she can schedule an appointment. Practitioners are surveyed for their accessibility to treat a patient with an urgent (emergent) condition and a patient with a non-urgent (routine) condition.

Many of these calls are from people who won’t even provide any insurance information on the phone. Supposedly the provider still has to provide an appointment. And if they don’t show up? Tough luck provider. You were just suckered by an insurance company’s “secret shopper” sham.