Dude, Pay My Claim

I really don’t like dealing with my HMO. If I asked for a show of hands for all those who find interfacing with their health insurance company a pleasant experience, you would probably get the same response if you asked the same group if they enjoy sticking a needle in their left eye.

When my family must interact with our HMO/PPO, this task falls to me, since I have a little more patience, being “in the business.” My wife did try to call one time. I begged her not to, but she insisted, saying we should share this burden. I reluctantly agreed, gave her the number, and walked upstairs to change. I came back down 10 minutes later, and she was sobbing into the phone, yelling “I don’t want to speak to a supervisor, I just want an answer to my question!” Last time she volunteered for that duty.

I really don’t have much trouble with customer service at our PPO. When I was in college, I sold books over the telephone. You know, the kind that once they start, they never stop coming? We had little flip charts: If they say no, go to chart 2, if they say no again, go to paragraph four on chart 3. If they say yes, get their info, etc. I lasted one half of one shift, and never went back, but it gave me enough experience to imagine how my PPO probably works.

I call the toll-free number, and keep hitting zeros until I am queued up. I listen to the Muzak version of Christopher Cross’ “Sailing,” and I am connected to my rep, Ted. This is one of the largest health organization’s in the country, and I get...Ted.

I always get Ted.

CSR: Thanks for calling. How can I help you?

Me: This is Rick Vassar, My member number is—

CSR: Dude, it’s me, Ted. What’s happening?

I began to think that Ted was the only one who works there, and my suspicions were validated the day I unknowingly and accidentally hit the prompt to speak to someone in Spanish. I was put on hold, listened to some song by Carlos Santana, and just before the guitar solo, I hear:

CSR: Hola, como le puedo ayudar?

Me: Uh, this is Rick Vassar, my member number—

CSR: Vato, soy Ted.

Me: Ted, I don’t speak Spanish, can you help me?

CSR: Lo siento ese, vato. Tienes que llamar otra vez y que te pasen con los que hablan Ingles loco.

I hang up and call right back, hit zeros, and get the “Sailing” hook again.

CSR: Thanks for calling. How can I help you?

Me: Yes, this is Rick Vassar, my—

CSR: Dude, it’s me, Ted.

Me: Hi, Ted. Listen, I have this claim—

CSR: Sorry, dude. Not covered.

Me: Why is that?

CSR: Uh, no referral—

Me: Well, if you look at the evidence of insurance, on page seven, paragraph four, it states that coverage should be afforded without a referral.

Silence.

Me: Ted, what’s the problem?

CSR: I told them this was going to happen.

Me: What’s that?

CSR: They told me nobody ever reads the contract...

In the past few years, class actions have been filed against carriers alleging unequal and improper claims handling, offering incentives to doctors not to make referrals, direction of care being dictated by managed care professionals and skyrocketing premiums. In 2003, some of these insurers settled their cases with doctors, agreeing to allow doctors to be doctors, increasing sensitivity to the patients’ needs and speeding up claims payments. Meanwhile, each doctor received enough cash after attorney’s fees to buy a venti latte at Starbucks. Many of these insurers have used this settlement as a marketing tool, reaping free good press well in excess of the amount settled in this “landmark” case. In fact, one of these companies’ stock price has increased over 250% since the announcement of this settlement.

But nothing has really changed. HMOs are still denying claims on a less than equitable basis, and they are denying portions of claims that are not usual and customary (to that particular company), and the patient is the one left holding the financial bag.

As a risk manager, I have a little better handle on what a company can and cannot do, so I can show them how they steered off the path. But millions of people do not know what their rights are, pay what they are told to pay and make healthcare decisions based on economics.

I have been very fortunate to get most of my claims paid, and I would have to hope that things are getting better. In the meantime, I have one assurance that I can guarantee with the utmost certainty.

I have Ted.


Reprinted from Risk Management Magazine.
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