last call

This afternoon, I had my coat on and had said my goodbyes when one of my coworkers said I needed to take a call...billing situation. The call was about a very similar situation as I described in a previous blog, except that this was a conference call to me and on the other end was the insurance company and the patient. A few days earlier I had a mild argument with the insurance company and afterwards called the patient to let him know the situation. I told him he might want to call the insurance company and see what he can find out.

You see, the physician's office has very little leverage. The patient pays his medical insurance premiums. Insurance company has the money. Physician performs service. Physician wants money. Goal of insurance company: collect premiums and pay out as little as possible. I can call every hour on the hour, but what do they care? Now the patient, or even better, the patient's Human Resources Department, they are the ones with some leverage.

So when the other end of the phoneline is the insurance company AND the patient, I am happy. I know the customer service rep won't be saying, "screw you, you ain't gettin' it." Not this time. Not with the patient listening. It was all very friendly-like and I was promised it would all get a good looking into.

And the patient thanked me several times for being so helpful. And he should. Because, honestly, it is above and beyond. As far as my boss goes, I should just send the patient a bill. Let him fight NOT to pay. But the doc only wants his money, and who can blame him?

I want to win.

conversation

after getting thru the electronic system, intentifying myself to the rep and giving her the patient ID, the date of service and the amount charged

"We received a copy of the Explanation of Benefits for this claim today, and it says it was denied because it is not covered under this patient's plan."

"Yes."

"I am a little confused, because we know that many plans don't cover this procedure code so we call to verify first. On December 9, I called this number and spoke to Marla at 1:55 pm, and she told me that it was covered at 90% of the contracted rate."

"Hold on."

a few minutes on hold

"This code is subject to medical necessity."

"Yes, did you receive the Letter of Medical Necessity that was sent with the claim?"

"Yes and it was not deemed medically necessary. You can appeal this decision to our Appeals Department."

"Well, we have had cases when there is a decision made that something wasn't medically necessary and we have gone through the appeals process, but in this case we've been told that it is just not covered under the patients plan."

"Because it's not medically necessary."

"But the Explanation of Benefits doesn't say that. It just says it is an exclusion of this plan. When something is found to be medically necessary we receive a denial that says that."

"You received a denial."

"Yes, but I need something in writing that says it was denied for not being medically necessary.

"It was denied and I just told you it was because it wasn't medically necessary."

"But I can't appeal this based on that. There needs to be something in writing."

"Well, we can't send you anything."

"Then I can't appeal it and I just have to bill the patient."

"Just do whatever you have to do."

hangs up

This conversation took place on the very day I decided to create this blog. We both were becoming increasingly frustrated and loud. Afterwards, I called back and got a different rep who confessed to being baffled as to why this claim was denied and amazingly admitted that this was never deemed medically unnecessary. She sent the claim back to be reviewed with an extensive note attached to it explaining the situation.

If I had to bet, I would say this will come back with an official denial stating it is not considered medically necessary and you can appeal by sending the required documents to.....

There is a lot more to say, but I will have to say it in later postings. I don't want to give away the ending, but you, the patient, are most likely going to be screwed.

open auditions

You know what would make this good? If I teamed this blog up with another worker drone like me, but from the insurance side. Someone who also thought the system sucked, but hates those friggin' doctors. If anyone out there knows such a person, direct 'em my way.

intro

I work for a doctor. A large part of my job is making sure that he gets paid for the services he provides, and an enormous part of that involves interaction with medical insurance companies. I think I have become quite good at it. From the beginning, I was awestruck at how the system works.

Our country's healthcare system is highly flawed. Almost everyone seems to recognize this, at least to some degree. I don't think there can be any doubt that the flaw stems from the fact that the entire system revolves around money and not healthcare.

My particular perspective is from the office of an honest doctor. I know a little bit about some of the ways that doctors pervert the system, and I hope to learn a lot more. But for now, I will have to report on what I experience...which is the near perfect money machine known as the medical insurance company.