<p>I know its frustrating for you when you don’t get the patient returning calls – but I really think that many patients are simply too baffled or overwhelmed to deal with it. And of course UHC banks on that. I’m sophisticated enough to look up procedure codes and also to track the progress of the claim online – plus, with a legal background, I understand all the terms of art used along the way. (For example, I know what an “appeal” is, I know the importance of submitting the “appeal” within a certain time frame, etc.) Keep in mind that when you are telling the patient one thing, that person is likely to call the insurance company claims processor and be told something entirely different – so the patient has good reason to believe that you (the provider) messed up somehow. It may be a lie, but that’s likely what the insurance claims dept. has told them.</p>
<p>calmom,
My billing person is WONDERFUL. She verifies benefits in advance, talks to the patient in advance of the appointments, tells them what the quoted benefit is and what their estimated payment will be at each appointment. She handles all filing and refiling and basic appeals (I have to get involved when it requires providing clinical information or responding to their incorrect interpretation of the benefit per their very own manual, etc. – ie when a “strongly worded letter” is necessary to file an appeal of a denial) ihandle that). We are not asking the patient to do her job. To the contrary, sometimes the patient accidentally confuses matters. YES - THE INSURANCE COMPANIES LIE TO THE PATIENTS. </p>
<p>We do everything within out power to get a claim properly processed and paid, per the quoted benefit. We know what we are doing. Sometimes, sadly, the benefits person (ofter offshore) didnt quote the benefit correctly, or, more often, the claims people are falsely denying a claim. But the patient has the ultimate responsibilty to pay their bill. We cannot make the insurance company do what they will not do. We have filed many complaints with the insurance commissioners office, but more oftent han not, insurance companies suddenly straighten up and fly right when the patient complains to their HR manager, or benefits manager at their company, who calls the insurance co. </p>
<p>My billing person is very polite and very clear in what her call is about. The courtesy of a return phonecall is expected. If they do not call back, and we cannot get the claim processed, they will be responsible for the bill. Believe me, I do everything possible to help patients access their healthcare benefit. But I cannot get blood out of a turnip. So if the patient is told a lie by the insu company, they should return our billing office’s call and find out what is needed to process the claim. They cant just ignore it and expect it to go away.</p>
<p>Youdon’tsay - Last year I had a very similar problem. My D was found unconscious on the bathroom floor of the dorm one morning. She had just showered and was getting ready for class. Her roommate called me and asked what to do. D was conscious by that time, and I said get her to the ER. At the ER they made her wait an hour or two, during which time roommie brought her food and drink. D had flu all week, and they tested for flu, and it came back postive. They sent her home with that diagnosis.</p>
<p>Insurance company (UHC) denied claim, saying that ER was not for flu. I pointed out that flu was the diagnosis, not the reason for going there. Found out from the hospital that they had no record of her being unconscious. I ordered copies of the records, and found out that they wrote that “patient c/o [complained of] feeling weak, faint.” Hospital flat-out refused to change code, based on what attendant wrote. (D says she told nurse she had passed out, but doc never asked. He heard about the flu, and stopped there. I think it was the nurse’s note.)</p>
<p>I wrote a letter to the insurance company, explaining exactly what happened, and offered them proof of what happened (contact info for the RA, etc). They paid the claim and I never heard anything more. I’m still angry at the ER, though, for sloppiness in record keeping. In general, folks consider what is written down to be what is true.</p>
<p>[Much, much later, we learned that D suffers from low BP - often 50 or 60 over barely there. A week of flu and a hot shower first thing in the morning before eating were not a good combination. Treating her faster, and looking a little harder might have prevented two further incidents!]</p>
<p>Interesting exchange between you two. I’m thinking that mistake is on the part of the hospital, not the insurance co., in that the hospital is using a code that isn’t covered. It’s in the best interest of the hospital to get the correct code in order to get paid, but I understand their position in that they probably think I’m asking them to commit insurance fraud. However, as I told the woman on the phone, this doctor has a specialty and, IMO, in the best position to understand the procedure done rather than a hospital that did hundreds of procedures that same day.</p>
<p>Am I approaching this correctly?</p>
<p>Cross-posted w/binx, who know really makes me wonder – am I going at this wrong and should be working the insurance company more?</p>
<p>Youdon’tsay – I think you need to be working both ends – keep after the insurance company AND the provider. </p>
<p>Keep things simple, and keep them in writing as much as possible. (That is, it’s better to write a short 2 sentence letter that gets to the point than to let your emotions take over and try to present a long argument). </p>
<p>Make a file at home and keep copies of every piece of paper and correspondence related to the insurance claim there. That way you have all paper handy when needed.</p>
<p>If you have a home fax machine, use it. Any time a communication can be reduced to writing and quickly confirmed, you are better off than relying on a phone call.</p>
<p>When you talk to someone on the phone – make a note of the date and time. Get the name of the person you talked too, full name if they will give it to you. </p>
<p>Don’t let yourself get angry or raise your voice – just be consistent and persistent. </p>
<p>IF this is an employer policy and there is a health plan administrator for your company, get that person involved as well. As I think I noted above, my problem didn’t get solved until I got the guy from Barnard who does the insurance stuff involved … and then the problem was resolved very quickly. It could simply be that he has the direct phone line of someone at the insurance company higher up the chain of command and could cut past a lot of red tape – I don’t know – but it certainly was worth having an ally.</p>
<p>We are talking about several different things here, but the consistent pattern in the successful processing of the claim was the patient/family involvement in the claims process. There is a difference between a referring diagosis and a final diagnosis. In binx’s case, the referring diagnosis was probably syncope, but the final diagnosis listed by the ER Dr, and picked up by the billing person, was the flu. It isnt right or wrong, its a different diagnosis. Totally agree, though, that ALL symptoms/presenting problems should have been listed, and the more listed, the greater the likelihood a claim will get paid, even if the diagnoses have to get flip-flopped on the HCFA (claim form). Not making excuses for the ER doc, PA, nurse or whoever documented the presenting symptoms, or whoever wrote the discharge orders. In our office, when we verify benefits we use the referring diagnosis. When we bill, we use that referrign diagnosis along with any others that are apporpriate.Its like billing for an xray to see if you have a broken arm. Even if the xray is normal, the referring diagnosis, trhe reason for the referral, is broken arm.</p>
<p>In our case, we get insurance companies stalling on payments, requesting records/reports, and then denying payment, claiming the procedure or diagnosis isnt covered (even when both the procedure and diagnoses were verified with their claims dept before the patient was ever seen).</p>
<p>I can understand why binx was frustrated that the discharge diagnosis wasnt covered, but she did what she needed to do to get the claim paid.</p>
<p>YDS- there are 2 codes when billing-- the CPT procedure code and the ICD diagnosis code. They have to use the procedure code that goes with the procedure, and the diagnosis that fits the illness/condition. Sometimes there can be more than one code to choose from ( for example closed head injury or head injury not otherwise specified= these are 2 different codes), or sometimes its as simple as needing a 5th digit on a diagnosis code (often needs a 0 or a 9 at the end). Those kinds of things can get fixed and rebilled. If I were you, I’d look first at your EOB and see what the reason for the denial is. Then call the billing office and see if it is a matter of resubmitting with another digit or code or what have you. They cant change a diagnosis or procedure without the Drs approval, but problems like that can get fixed, especially if the procedures were preverified. </p>
<p>The challenges we as providers have faced in our little offices (where most of the hospital based problems described would not occur) are errors, falsehoods and ignorance on the part of claims processors, who have about 10 seconds to process a claim, and the failure to reasonably respond to an appeal that addresses the nature of their claims denial. In my case, with UHC, I was working with an internal subject matter expert (a doctor employed by them). He totally agreed with me, tried internally to get claims reporcessed, wrote additional supporting documentation to attach to my appeals letter 9that contained proof fromt heir very own internal policie manuals that a procedure and diagnosis was covered) asn we still got nowhere. This has been going on for a year. Only when the patients got their HR departments involved did we get some movement. All but one claim has been correctly processes, but as someone said above,t hey count on most people to give up and go away. they know the rules of their game-- the patient doesnt. It is a sick system and needs to be fixed.</p>
<p>Just wanted to bump this and thank everyone for their help. </p>
<p>After getting a second bill this weeekend for the $8K, I called back BCBS and learned the hospital didn’t amend and rebill. I called the hospital back and didn’t even have to talk to a mgr. The woman who answered was able to tell me that the billing mgr met with the doctor and that he rewrote his op report and so they did refile on April 7. The bill just crossed in the mail. With any luck, this will be taken care of this time around.</p>
<p>Keep us posted! Hopefully it will process and pay correctly. Don’t give up!</p>
<p>Youdon’tsay, I hope this finally clears it up for you. What a pain! Threads like this make me very happy that I live in Canada. Well, lots of other things do, too, but healthcare is near the top of the list. :)</p>
<p>It only took about 2 years for me to get my batch of bills paid the 1st time I went to a provider out of state because the local providers were making me worse & worse. We tried to get pre-authorization, but our carrier insisted none was needed. I was embarrassed that it took so long, but the provider reassured me that it was PROMPT payment!</p>
<p>It’s important to keep communicating with insurer and provider but stay calm & don’t take the hassles personally. Insurance is a business and the longer they can stall payment and more payments they can deny, the more money they make. It’s unfair and nasty, but that does seem to be how many of them operate. I was a plaintiff’s attorney and when we would start muttering about working with the insurance commissioner and filing claims for bad faith, suddenly insurers got more cooperative. ICK!</p>
<p>Another thread reminded me to bump this with a big THANK YOU!</p>
<p>Upon the hospital resubmitting, my portion of the bill went from more than $8,100 to $155. Phew.</p>
<p>Glad it was straightened out.</p>
<p>Glad things worked out for you YDS!</p>
<p>I hope they work out for me too… check my latest post in the 2010 thread. :(</p>