I have a good rant as promised- Medical bills. The insurance category might be one of the shadiest operations in all of business. Their business model is basically to take in money (from your premium) and then pay out far less than what they bring in, overall. If something big happens- a Katrina sized incident, they rely on the creativity of their lawyers, who drafted in clauses like “an act of god”. Then they deem Katrina an “act of god” and wipe their hands of it, leaving thousands of loyal premium-paying customers screwed. But I digress… In the medical side, it is the same business model, take in more, delay by sending you countless forms to fill out (while earning interest on your premium and hoping that those forms get lost in the mail or not filled out properly) then pay out less than what is brought in. You have to play the game though… the cost of health care is so high that you can’t chance it without insurance. My favorite is the form they send you to see if there is anyone else they can sue related to the incident. Don’t fill that out and get it back to them? They deny. Lets take a look at one of “Scott’s” bills.

Scott has an incident. Scott gets medical treatment for said incident, supplying provider with cards and info for his medical insurance. The provider bills insurance. Primary insurance denies claim until $25,000 has been paid (don’t ask). Secondary insurance comes into play. Provider: “Oh, We don’t bill that insurance company… we only bill in our network”. What the heck?? Don’t you want to get paid? Ok, no problem… Pass bill to Secondary. Secondary needs denial explanation from Primary. Primary wasn’t actually billed properly because of a change to the system half-way though incident time frame. Third insurance gets involved. (yup.. got three) Everyone points fingers at everyone else saying that they someone else should pay “we need explanation of benefits from the other two”. Useless “incident reports” are mailed to me, threating to deny all claims unless filled out. 8 months pass. I throw away letters that inform me that “we have received information in regard to your claim and are currently processing it…”(yet not saying what they received or what they were going to do about it) what a waste of paper. Secondary still needs Primary’s explanation of benefits to process claim. Now that 8 months has passed, it is too late to re-file that claim.

Sent to Collections. Mean sounding man calls me asking for my credit card “you need to pay today, sir”. I bore him with the depths of my trifecta insurance debacle until he hangs up. Amount in this debate $89… damage to my credit… priceless. Problem: the hospital did not bill first insurance properly so I could send the denial to the second, even after two separate calls from me to rectify the situation.

Claim in a different state/ city than where the insurance company has their “network”? Oh boy, this is fun. Get some PT one place, a surgery in another, rent your CPM machine from another (as one has to). Each area based on the location of the service provided, has a different network, “Out-of-Network” charges, “We Don’t Bill That Insurance”. That would be more manageable if things didn’t change mid-stream. When the insurance providers change over (reached your max for example) for THE SAME PROVIDER, the new insurance pays a different amount or isn’t in their network, so they can’t bill them or not for the same amount or it is no longer covered.

I called an agent and asked why they couldn’t just get the info directly from the other insurance company… She replied that her company does not talk to the other company involved “Insurance companies don’t talk to one another”- it was my responsibility to get them the info. Ok… I know they don’t want to do anything that would expedite them actually paying on a claim, but they have to communicate with one another… otherwise they would overpay if they didn’t know what the other company had already covered.

Your co-pay… You owe 20% of the first $5,000 paid. Think that is just $1,000? Wrong. With “insurance math” that is actually $1250. (You owe 20% until THEY have paid $5,000 so you owe more)

Scorecard? Scott 0, five inch stack of paperwork, 1.

Oh, and providers… They will bill you $1000 for a knee brace… but they will take $150 to clear up the bill. I used to wonder about that, until I realized that they have to do that to get paid what they need to by the insurance companies. It is not so much the providers… it is the insurance that needs to be smote with a swarm of locusts.

Whew… think I am done. That felt good.

This entry was posted on Sunday, April 27th, 2008 at 8:33 am and is filed under scottmacartney. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.