Everyone has heard about the problems with health insurance. We all struggle and fight with insurance and what I’m about to share is by no means an isolated, new, or tangibly different case than any of the vast number of mis-handled claims and situations occurring in the United States every single day. However, I’m going to share it anyway because I’m sick to death of the crap we put up with every time we go to use health insurance. It’s fundamentally broken and no I don’t believe that national health insurance would be any better; it would be broken for the same reasons because the same bunch of idiots would be put in charge of that system too.
Every story begins with a premise. My premise is that I have an “out of network” provider. I’ve been going to my provider for a long time. When I started with this particular doctor I was with a different health insurance company and the provider was “in network”. I understand that different companies work with different providers, I’m just setting up the premise. For better or worse, I’m seeing an “out of network” provider.
I’m try to be a educated user, especially when it comes to health insurance and I understand that when seeing someone out of network, it is a wise idea to understand as much as possible about how this will affect the claims process. Being a good insured party I called Providence as soon as we switched health insurance plans in order to gather as much information as possible about how much it would cost to see my provider out of network so that I could make an informed decision. I wanted to have all the tools to decide whether to pay the extra to stay with someone who knows my full history and has all of my up to date records, or if I should switch and play doctor roulette with someone in network.
After 30 minutes on the phone with a claims representative from Providence, I was assured that the rule for out of network providers was that the patient incur 20% of the charges as a deductible. Despite the obvious frustration of the representative on the other end of the line, I confirmed for a second time in plain English that if my provider charges me $400 that it would mean I owed exactly $80. I was assured that yes $80 was 20% of $400 and that yes that was how it worked. Great! I can make an informed decision about whether or not I want to pay $80 with someone I trust or a standard $15 copay for someone in network but with whom I have no previous relationship.
The Claims Process
I decide to move forward with my “out of network” provider. It sounds like such a dirty word for someone who was “in network”, a “preferred provider” only a few months before. The process is such that I pay the full amount for treatment out of pocket up front and then my provider submits a claim form to Providence who in turn cut me a check for 80% of the amount. Not the most glamorous way to handle the process in the digital era but painless enough to suffice. I paid about $1,200 for treatment in early July and patiently (ha!) waited for the paperwork process to do it’s thing.
Yesterday I receive a letter indicating that my claim has been DENIED. It said it just like that too, in all CAPITAL LETTERS. After the initial “mallet to face” expression had worn from my shocked visage I took up my phone and dialed the number cited for explanation of benefits. I explain the situation to a claims representative at Providence, providing my member number, claim number, shoe size, and the specifics of my morning meal and then wait while he pulls up my records on his system. It turns out that the reason the claim was denied was because of a clerical problem with the claim form. This is where the story takes a turn to insanity:
NPI numbers are now also required in column J
People wonder why I’m such a fucking cynic. I grew up listening to Monty Python sketches about having to file forms in triplicate on the third Sunday of every month under a full moon using only fresh bat’s blood on pure elephant skin parchment. It turns out that the reason my claim was DENIED is because Providence (or rather Hipaax) changed the way their claims forms worked recently to require that the NPI number for providers not only be filled out in box 33a but also copied to both slots of column J. Why the hell do I know this? Because the claims representative proceeds to tell me that although he is staring right at my provider’s NPI number, the claim is denied because it doesn’t also appear in both slots of column J.
Huh???!??? Are you serious? Are you telling me that with all of the sloppiness employed on every form I’ve ever seen filled out by every half-ass agency I’ve ever worked with that this number can’t just be copied from field 33a to column J? That’s got to be pretty much the lamest excuse I’ve ever heard on the failure of an internal paperwork process.
Correcting the Problem
Moving forward productively, I ask what the next steps are towards fixing this problem. The response I get is: “Well, you’ll need to have your provider submit the forms again.” I ask if they have notified my provider of this. “No.” I ask how my provider was ever supposed to know to resubmit these forms. “Not our problem.” Well, aren’t you a helpful bunch of bouncing bunnies then! Basically, they will just deny my claim, send me mail to this effect two months after the initial form was submitted and leave it to me to sort out.
I “talk” with the representative for a few more minutes and he agrees that perhaps it would be a good idea for him to contact my provider and explain the Providence process directly to them. Something told me that I might not be up on all of the latest details of their forms. The final icing on the cake I learned from all of this is that when Providence (or rather Hipaax) changed their forms and requirements, they didn’t actually notify any of the providers. That’s brilliance! “Yeah”, says my claims rep, “we’ve been seeing an enormous amount of these returned claim forms since that change went through.” Hmm, I wonder why?
Remember how in pre-authorization I’d checked that I would be responsible for 20% of the cost of treatment. “Bzzzztt!” Not true. It turns out that piece of information was flat wrong as well. Despite the fact that repeated the information to the representative twice when initial inquiring, despite the fact that I asked specifically if for $400 of treatment I would owe $60, it turns out that the information was plainly incorrect. A total lie. Bullshit. Not worth the half an hour of calling in the first place anyway.
In fact it turns out that of the $1,200 I have spent so far I will be receiving about $550. How could this be?
Average National Rates
When a health insurance company receives a claim for treatment, they first compare the cost of the treatment against an average national rate for that treatment. If your doctor charges $300 for a treatment that they perform, the health insurance company compares that amount to the national average for such treatment. If it is found that the national average is only $120 then that is all they oblige themselves to cover. You pay $300, they decide you are owed $120 minus the 20% deductible. So in fact they owe you about $102. You pay $300 but you receive $102.
How are you supposed to know this up front? Well, the representative told me I should have called before beginning treatment to get pre-authorization. I did that. I called, I got pre-authorization, I even cited the actual amounts for certain treatments to ensure that I fully understood exactly what I would get back. “Well, pre-authorization can’t always be accurate if you don’t provide all of the information.” I’m told. This is starting to piss me off (yeah, starting, I know….) so I decide I’m going to pin this guy down. The following dialog transpires:
Me: “Can you tell me exactly what amount I’ll be receiving when this claim is fixed?”
Rep: “I can tell you the maximum you might get back, but it will probably be less than that.”
Me: “Wait a minute. Why can’t you tell me the exact amount? When the form is fixed how will you determine the amount?”
Rep: “I’d need to know information about your provider.”
Me: “You mean the information that’s on the form in front of you?”
Rep: “Urmm, err…errr….urmm”
Me: “Why can’t you tell me the exact amount that I should receive back?”
Rep: “When your claim processes, we’ll mail out notification of the amount you received.”
This highlights one of the most worrying aspects of this whole process. The insurance company cannot actually tell me how much money I’m going to get reimbursed even with a fully filled out claim form right in front of them. These people work there. They are trained specifically in the unique processes of their company and they cannot tell me how much money I will receive from this claim. If they can’t figure it out, how the hell am I supposed to navigate this mess?
The conclusion of all of this dear reader is that I still have no clue how much money I will receive for my pre-authorized treatment. I’m still about $800 away from the conclusion of it and will be out a full $2,000 when all of this is said and done. I have no idea how much I will get back from that nor when I will actually see the money if I ever see it at all. Bear in mind that this was for pre-authorized treatment.
I am a consumer and yet I know about Hipaax and box 33a and how an NPI number now needs to be copied from box 33a to two slots in column J. Why the hell do I know this? Why is this useful information for me to have in my brain? Why have I so far spent hours on telephone calls for a single set of treatments?
I don’t use health insurance very often. I have little cause to use it in the future. I can only imagine what this is like for those people who rely on health insurance to treat serious conditions every day of their lives. It must be a living hell.
Had I know up front that the evil Providence were going to trick me out of money I would simply have elected to pay for the treatment in cash up front and avoid going through insurance all together. If I had paid cash my provider would have offered a 15% discount. They do this because going through health insurance companies is a waste of time for them as well. 15% of $2,000 is $300. As far as I know that $300 savings may be more than I ever see back from Providence and after the effort that has been taken to wrangle whatever amount I get from their clammy fingers it may still have worked out better to just shell out the $1,700 in the first place.
The system is broken. It will remain broken for as long as we do nothing about it. These companies are receiving more than a thousand dollars every month in insurance premiums from me and that is just the parts of it that I can see myself and my employer contributing. When I finally have a single claim to make I have to fight and scrabble, end up tricked into getting a meager percentage of my original outlay. This is ridiculous. It’s daylight robbery and I hate having to stand for it.
If I can find any way to vote against health insurance companies, national health insurance, or any kind of covered insurance you’ll be damn sure I’ll do so. I want to be informed. I want to understand the system. I want to make better choices. Right now I just feel cheated. I can’t accept that any “new” scheme with the same companies and similar policies is going to be any different.
Honestly what I’d prefer is to be given that $1,000 every month in health premiums and put it in a savings account. Put it in a special savings account that can only be used for health claims. When I need something from there, I’ll expense it from that account. If it’s more than is in the account, I’ll have to pay out of pocket. It’s exactly what ends up happening today; I pay out of pocket anyway! Instead it would cut out the entire bullshit layer of health insurance companies like Providence that use cheap tricks and marketing propoganda to introduce an empire of profiteering. You want national health insurance? Start a program to give every person in the country an account like this. Pay every person in the country a premium per month into this account. Remember, it can only be used for health expenses.
Remove the health insurance companies now! They are broken!