Last week, I was invited to provide a 10-minute presentation about Healthassist services to a lunchtime meeting of the Entrepreneurial Women’s Club. I began by asking the audience if anyone had ever experienced frustration with the healthcare system. There were lots of sighs and chuckles, of course!
When I asked for examples, a few people mentioned issues with physicians (providers). But there were many more comments regarding frustrations with health insurance companies themselves (the payers).
Having spent approximately four hours on the phone the week before to troubleshoot a bill sent to my father, I could relate!
A little bit of background…
My father is enrolled in a Medicare Advantage plan, as are 20 million other Medicare beneficiaries (34% of the total). We selected this plan together because of a unique benefit it offers, something called a “Passport Program.” As the name suggests, this allows my dad access to a wider scope of doctors and hospitals in the insurance company’s provider network, something that is important since my dad spends five months of the year in New England and the remainder in Florida.
The program is uncommon, so we are always prepared to provide written information to each doctor’s billing team, so they know he is not required to obtain a referral and that their services are considered “in-network” — and, therefore, paid for at a higher rate.
Each May, when my dad comes to New England, he calls the insurance company to turn on the benefit. Every October, he calls again to turn it off. He’s been doing this for years and it’s worked out beautifully as he has utilized the healthcare system quite a bit and his out-of-pocket costs were kept to a minimum.
He did it again this year, knowing he was having knee surgery. Needless to say, he was shocked when they sent the bill and told him his benefit was paid at the out-of-network rate. At that point, I knew it was time for me to get involved.
Getting to the bottom of things
During my many hours of calls, I encountered several customer service representatives who told me some or all of the following:
- The Passport Program did not work the way I thought it did
- My father had not turned on his Passport Program back in May
- Neither his doctor nor the hospital was an in-network provider (even though I was staring at the insurance company’s web site which listed them as such)
- The claim was processed correctly, and my father was responsible for the balance
After polite insistence that the situation be escalated, I finally encountered a knowledgeable and competent supervisor who agreed to research the situation and get back to me, in addition to giving me her direct phone number.
Fortunately, as of this writing, I have received three updates, all of which have confirmed that the providers were in-network and that the claim is being reprocessed.
Whew! It’s hard not to feel frustration and resentment at the amount of energy and effort I have spent on getting this corrected — and I do this for a living! I can only imagine how it feels to someone who does not.
Recommendations for getting better results
I make it a practice to scrutinize all bills from medical providers to ensure claims were processed correctly, according to the outline of the insurance contract. If something does not make sense, I begin calling.
Here are some suggestions for managing your insurance products:
- Know what insurance plan you bought and appreciate all the requirements of the product, for referrals, notifications, etc. Follow the rules as outlined in the contract.
- If you have someone in your life capable of helping you troubleshoot issues, research how to give that person permission to call on your behalf and complete the necessary paperwork.
- When you receive a bill and don’t understand it, call the provider’s billing company first and ask how it was paid by your insurer. See if that matches what you read in the policy. For example, if in-network benefits were supposed to be covered at 80%, was it paid that way?
- Call the insurance company next and have your ID card, the bill and any other paperwork about the bill in front of you.
- Look up the benefit in your policy/evidence of coverage so that you know how the benefit should have been paid.
- Keep a running list of times, dates and people you’ve spoken with when you call. Ask if they are documenting your interaction in their system.
- If you don’t feel comfortable with an answer, call back at another time and get another opinion. If you are still unclear, ask for an escalation to a supervisor.
- Maybe most important, be extremely polite and diplomatic. That’s important in getting the results you want. For example, I found myself saying the following:
“Please help me to understand what you are telling me as it is different from my understanding.”
“I know you are trying hard to assist me and I appreciate that. I find we are not in agreement; can we pull in your supervisor for a consult to help me understand?”
“I appreciate your efforts. I’m just not satisfied with this outcome and would like it escalated to someone else in your organization. Who can assist us?”
Conclusion
Conducting extensive research when choosing an insurance product is necessary to help you understand what you are buying as well as how best to use the product. But it doesn’t end there. Make sure benefits are paid as they should, be assertive, and question when you think a mistake has been made.
Oh, and practice some deep breathing and relaxation exercises before making any phone calls about bills and claims!