Treating Foreigners , Part I | The Life of a Hotel Doctor

As years passed and my reputation grew, I acquired a source of patients I never knew existed: foreign travel insurance services. They had names like Universal Assistance, Assistcard, AXA Assistance, Europ-Assist, Usa Med, Mondiale Assistance.

Aware of America's insanely expensive medical care, few foreigners (and no Japanese) arrive without medical insurance. Some foreign carriers resemble ours -- meaning they're infuriating to deal with. They require policy holders to pay the doctor then apply for reimbursement once they return home. This gives the carrier a chance to save money by denying payment on the grounds of incorrect information on the reimbursement form. I received many pleading letters from former patients who enclosed cryptic documents in an effort to pry money from their policies. Western European carriers preferred this method.

Carriers in South America and Asia hadn't learned the latest tricks, so they were positively delightful to deal with. Their clients simply saw a doctor who billed the insurers, all of whom had offices in the US. Some doctors refused to take a chance with an unfamiliar carrier, insisting on money up front. I had a rule about not making difficulties for hotel staff, so when they began asking me to see patients and bill a foreign insurance agency, I complied with a heavy heart, but they all paid.

Readers who are not physicians will wonder what all the fuss is about, but anyone familiar with how American doctors get paid will be flabbergasted to learn that foreign insurance agencies paid whatever I asked; they never paid less. I wrote my bill in plain English. I never added a special code for every diagnosis and procedure (American insurers require this). I didn't itemize and explain everything. Finally, billing didn't require extra paperwork. Since the patients weren't paying, I didn't give them a copy of the record I filled out in the room but faxed or mailed it to the insurance company. I loved it.

Nothing is perfect; the carriers' American offices were probably small and poorly computerized. Some paid slowly. I kept an eye on unpaid visits, phoning after two months if a check hadn't arrived. No one stiffed me, but an agency called Assistcard required far too much pestering. After dozens of calls about missing payments, a clerk revealed the agency's policy.

"We pay after 120 days."

That was too long. I insisted on quicker payment but in vain. Ultimately I began sending Assistcard a bill with the amount left blank. Across the bottom I wrote in longhand "if paid within two months, pay $150; if paid after two months, pay $200. Assistcard checks arrived as slowly as before, but they paid the $200.

Once these agencies realized I was always available, they called regularly, eventually making up twenty percent of my business. Given a choice, I prefer a patient who doesn't hand over cash at the end of a visit. Much overlap exists between delivering good medical care and making a patient happy, but it's not a hundred percent. Patients who feel someone else is paying tend to be less demanding.

And, of course, they're foreign: more respectful than Americans, less inclined to argue. Partly this stems from difficulty communicating in another language and feeling helpless far from home. It's also true that doctors in most countries exert unquestioned authority. This is probably not a good thing, but I can't deny feeling flattered to be the object of such deference.

Just as quickly I discovered the downside. Medical practice turns out as distinctive from country to country as food. Perhaps not serious medicine; doctors treat heart attacks and fractures more or less the same around the world. For minor ailments -- colds, flu, upset stomachs, fatigue, anxiety -- science makes a contribution but tradition trumps it. I'll explain what patients from various countries expect from doctors in my next column.