PLATTSBURGH -- On the surface, health insurance seems like a simple concept: The patient provides a health-insurance card to the doctor, and the insurance company takes care of the bill, excluding any patient co-pays.

But as with most anything else in life, insurance coverage is decidedly more complex.

An array of twists and turns throughout the process often goes unnoticed by the patient but can severely impact a North Country physician's ability to operate a business -- and even determine whether a doctor can afford to practice here.

PAYMENT CONCERNS

Physicians establish contracts with insurance companies to determine what kinds of reimbursements they will receive for specific kinds of patient services.

It is not uncommon, however, for insurers to pay considerably less than what it costs the doctor to treat a patient. That is when individual physicians may decide not to accept certain insurance coverage.

"Physicians, in general, like to accept all insurance coverage," said Dr. Wouter Rietsema, director of physicians for CVPH Medical Center. "But in a community like Plattsburgh, where the doctor is a small businessman, sometimes insurance companies' practices are unacceptable."

In larger urban areas, doctors often form partnerships with other physicians, which gives them added clout when negotiating contracts with insurers.

In the North Country, where there has been an alarming decline in the number of practicing physicians, doctors have to go solo against the insurer and can't always negotiate for more amiable reimbursements.

"At some point, the doctor can't justify accepting an insurance that's not meeting his cost of business," Rietsema said. "The typical primary-care provider has an overhead of 60 to 70 percent. In the end, sometimes the doctor has no other choice" than to not accept a particular coverage.

"Patients will think that they have good insurance coverage, but they don't realize their doctor is not getting a reasonable compensation for their services," he added.

When doctors do discontinue relations with a specific insurer, it is with the hopes that that action will force insurers to renegotiate their contract with the physician to provide better reimbursements, Rietsema said.

Doctors can also dispute reimbursements they receive for individual payments. For instance, if they submit a bill to the insurer for a Level 3 service (which pays higher than Level 2) and the insurer only compensates at Level 2, they can collect records to prove that they provided Level 3 coverage.

"The doctor has to expend an extra amount of effort to go that route," Rietsema said. "That could also represent a financial burden."

AREA LOSING DOCTORS