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Friday, September 4, 2009

Healthcare Makes Me Sick

"After very careful consideration, sir, I've come to the conclusion that your new healthcare system sucks."

I’m not going to get into a debate over single payer insurances, government run healthcare or any of that. Quite frankly, I have a bigger problem with how the current system is managed and quite frankly, if competition is a good thing, I hope it inspires the players to step up their game and become better proponents to reform instead of being obstacles. Currently, the left hand doesn’t know what the right hand is doing and the right hand is currently underneath its own seated ass, becoming numb in order to perform The Stranger.

Back in May, my daughter caught the stomach flu. In February she had come down with it and passed it along to myself, my wife, and my wife’s parents. This time, none of us seemed to get it, which was good. However, to see this rambunctious child, who runs around constantly, lying on the floor and unresponsive to various stimuli gives a first time parent pause. We had taken her to the ER in February and they pretty much observed her and sent us home after a few hours. My insurance, at the time, had a $35 co-pay. No big deal. Fearing this was more severe a case, we made the decision to take her again and she was found to be severely dehydrated. We had tried giving her juice, Pedialyte and anything else to keep her fluids up but she refused.

We walked into the ER and she just sat there in my arms, something she hardly ever does, anymore. They took her to cubicle and pumped her with two bags of IV fluid. Her fever spiked at 103 and they administered medication to reduce it. Since she had been vomiting anything she ingested, they had to do it rectally. After a few hours of trying to bring down her fever, the ER docs made the decision to admit her. Now, this was the hospital that our daughter was delivered two years ago. Since then, the hospital was acquired by a bigger group and the Obstetric and Pediatric care was dissolved. This meant an ambulance ride to a nearby hospital. From there, she was released later in the evening.

Now, here’s the problem and let me preface this by stating that I have no issue with the care she received. I am grateful for it. She was a completely different kid when she got released as the pictures will attest to. That being said, what followed was a complete and utter breakdown of communication, administration, and severe frustration on the part of my wife and I concerning the billing of this stay.

Little One at the ER before being admitted.

Little One playing with balloons before being released.

As I said, before, my insurance in February had a $35 co-pay for ER visits. Our insurance was changed at the employer level and the new provider and coverage, which begun in April, had a $100 co-pay for ER visits. If you were admitted to the hospital, that co-pay was waived. We also had a $100 deductible per family member, which my employer opted to waive for the rest of this calendar year because of the transition. So, for those of you playing at home, with no prior medical billing experience, what was my total bill for the ER and Hospital stay*?

a) $0
b) $100
c) $236
d) $136

For those of you who chose a), you made the same mistake as me. I received two separate bills from this event. One was the co-pay for $100. The other was a bill from the ER doctor’s practice in the amount of $136. Now, before everyone flames me for being nitpicky over $236 remember, I had a $100 co-pay that was waived on admittance, and no fulfilled deductible for the remainder of 2009. I admit that if I was responsible for paying the full amount under any other circumstances, I would be glad to. My daughter’s well being is worth millions.

However, I felt that there was something rotten in the state of Pennsylvania, and I wanted it take care of one way or the other. Most adults will handle the situation in of two manners. They will call and track down the responsible parties, confirming or debunking their responsibility for paying the bill, or they will just let it sit and hope that it goes away. I prefer a more hybrid approach. I let the bills sit while I contact our internal support folks in these matters and ask them what the hell is up? Unfortunately, in this instance, no help was really available.

So, the $100 co-pay bill kind of sat in a pile, soon to be joined by a reminder and finally a letter from credit and collections in the matter. All the while, the issue was being investigate by internal associates who met with brick walls and unanswered emails. Then, the Explanation of Benefits came along and stated that the Insurance provider had fulfilled a portion of the services at the ER and that the doctor had the right to “balance bill” the member for the remainder, which was $136. If you’ve ever looked at EOBs it’s hard to understand sometimes but eventually once you sift through the medical mire of line items and coding you can find out the important stuff.

I took the reins in the matter and made several phone calls and left several messages. The billing parties were conveniently holding office hours while I and my wife worked which made it near impossible to get a hold of them in person. Finally, we called the insurance company to get some explanations.

In the matter of the $100, the insurer stated that my daughter was an outpatient observation case. I said, “Then why did they admit her?” The rep could not answer me. This was beginning to look like a case of clerical error made on the part of the hospital. After all, the patient advocate who helped in the transport of my daughter when she got admitted said that she was being admitted and that the co-pay was going to be waived. So, I started calling the hospital, the billing department and anyone else who could tell me what was going on with this thing.

Finally, I got an answer from someone totally unrelated to my daughter’s care. A doctor, who was listed as part of the practice that treated my daughter at the hospital, got on the phone after medical billing gave me her name and number. She did not remember treating my child nor did she understand how I got her information. She did, however, take the time to delve into the case and stated that my daughter was admitted as Observational as most pediatric Gastro patients are. So, I was pretty much screwed on that front. The insurance provider said that I would have to get the doctors to re-bill the visit as inpatient and this doctor was telling me that this wasn’t the protocol in my daughter’s case. So, why couldn’t anyone involved with the matter explain this to me? I would have hemmed and hawed and cursed insurance companies for a bit, but would have paid. I did pay it, though, once someone had finally explained it to me.

Now, the matter of the $136 came to my plate as it was billed in August, almost four months after the initial hospital visit. I explained to both the billing office and the insurer that we had a $100 deductible and that would negate the $36 left on the bill. Also, being that our deductible was fulfilled automatically by my employer, I should be free and clear, outright. Apparently, that wasn’t the case. It was also odd that there was no mention of amounts on my EOBs as there had been with the previous insurer. Each EOB used to come with a breakdown of your responsibility towards fulfilling deductibles, in-network and out of network amounts. The new carriers were lacking in this department. Regardless, at the bottom of the EOB for the $136, it stated that the carrier paid the maximum amount for “in-network” providers and that the provider that treated my daughter was “out of network.”

I read that statement a few more times. From what this stated, the hospital system that I visited was in my network, but the doctors working in the ER there were not. Now, how is that even a logical premise? According to what I’ve been told by people in the business, the new methodology in healthcare providers is to stop holding the hand of the member and explain to them that they need to be an informed consumer. That means that when you go to an ER and request treatment, you need to determine if the doctor assigned to your case is in your network. So, regardless of how severe the situation is, whether it be the stomach flu in a two year old or a severed limb packed in ice next to you, you need to ask for a list of participating providers before receiving care.

Another suggestion by insurance carriers today is for members to shop around for care. Ask if there are any specials or benefits to getting care there. Imagine that scenario, “Yeah, I need to have kidney transplant. What specials are you running today? Two for one? Great. Now, can I have the SSN attached to that kidney? I’d like to go online and request a donor history report.” I’m sorry, but if my daughter is listless and expelling fluid from either end of her being, I’m going to the ER and asking for care, not credentials or a menu.

So, I called the insurer and explained my disbelief over this flawed process. They offered no sympathy and continued to be the Teflon carrier pushing the matter back to everyone else but them. I called the ER and requested to speak with the doctor listed on the bill as the presiding physician. They said she was not on staff, there. I called the billing department at the hospital system and they did not even know who this practice was. Not to mention they said that this matter had taken place before the merger. I informed the person on the phone that was impossible; otherwise you would not have sent me into collections over a co-pay from that visit. You can’t have it both ways. They were completely clueless over the whole matter. They informed me to call the billing party. I had already left a message and received no response. Finally I started to formulate a theory as to what was going on here.

The ER that treated my daughter was still doing business as they had before the merger. The hospital continued to let them do so with only dotted line responsibility. This is why they had no clue as to who this physician or practice was that treated my daughter. This also gets them into a double dip area where they recognize the hospital as a part of their network but allow them to staff with people who could be considered out of network. It would make more sense for a hospital system to operate as a whole entity in terms of membership to providers. It makes for a one process system instead of bolt on processes that can bastardize the system as a whole. This was neither here nor there. I wasn’t in the business of fixing the system, just being screwed by them

After getting the run around for three days over this, I finally got a response from my internal contacts, two months after initiating the request. I was told to contact a rep from another company and explain the situation. Now, this was the original co-pay problem, not the bill. She explained what I had already found out, that the visit was, is and always shall be an observational event. However, when I mentioned the other matter with the “out of network” providers wandering the ER and treating patients, she became intrigued. She said she would put a hold on the account and investigate further.

Within an hour, the entire matter of the $136 was cleared up. The insurance carrier had an error that systematically declared the provider as an “Out of Network” group. Because of that, I got billed. The problem was fixed and I was going to receive an updated invoice for $0. She also initiated a fact finding mission to how this happened to make sure it didn’t occur in the future. Unfortunately, I see two problems with this.

  1. Will they go back and investigate other claims made by this provider that were not fully reimbursed because of the glitch? Obviously, they either didn’t catch it before my case or had done so and took to remitting the balance of claims to the provider only if someone cried foul in each case.
  2. How many other providers experienced this glitch in their system? How many other parents or patients experienced this same ridiculous event in other hospitals across the state, or even country? The level of accountability and transparency over ownership in such matters is shoddy.
I called the insurer on three separate occasions, each time being pushed back to someone else. Another call to another entity. That person pushed me back to the carrier or to another party. If they would have just confirmed with the provider whether or not they were a member of the network, this could have been resolved. Of course, if I would have called as soon as I got the bill, it might have been. But even so, the event happened at the beginning of May. The rebill to me occurred less than two weeks ago.

This is my issue with the system as it is. Yes, premiums are skyrocketing. Yes, the level of involvement by insurance companies in your care is increasing. Yes, the economy sucks, people are unemployed, and have no insurance. But inside that system that is flawed resides a bigger problem. Not the costs associated with the care, but the administration of that care and the communication between the provider and the insurer is flawed. It shouldn’t be this hard. How many elderly or individuals with reduced capacity have been bilked out of hundreds or thousands of dollars because of a fundamental lack of understanding of how medical billing works? How many actually suspect a problem and contact a patient advocate to investigate?

The other problem lies at the heart of medical insurance, coding. The process shouldn’t be that hard. If you are going to issue insurance to someone and state that they are responsible for a co-pay, unless they are admitted, then they need to stop the line right there. If you are going to say, “If they are admitted, the co-pay will be waived unless the following happens… that’s where you start to dilute the message. A or B, not A.1, B.2, B.2.3. This will solve two problems. First off, you’ll get paid quicker. If there is no debate over if A or B happened, then there is no question of ownership. That leads to the second problem being solved. If you state that either you will or won’t be billed based on a set number of actions then you don’t get people calling you up to complain, debate, or question the matter. This leads to a reduction of service requests made on the call center. That leads to a reduction in escalations and man hours spent investigating the matter. I could go on down the line to the actual cost of an employee to a company involved in any given dispute but who cares. The matter is simple. You pay or you don’t. This meeting of certain criteria revolves around a interpretation of procedure or a refusal to see outside the box. Take thinking out of the equation. Yes or no. Was that person admitted? Then the co-pay is waived. Did that person get released from the ER? Then they pay.

I said before if the matter was not up for debate, I would have gladly paid off the balances and just gone about my way. My daughter’s health is more important than a couple hundred bucks. But, I’ve learned to not accept anything at face value. I should understand the importance of my care and my dependents and seek out the best possible choice that results in proper care at the proper cost. I bet the insurance company didn’t think that meant them in this equation. I know better. I am an informed consumer. Now you are, too.

* The correct answer was b) $100. Additional costs were eight ibuprofen, a few bruises from banging my head against my desk, and the color from a few hairs.

1 comment:

Anonymous said...

This topic always comes up in my medical coding school, naturally. Obviously people are going to be divided, but there will always be people out there dedicated to healthcare.

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