Tuesday, October 09, 2012

Health Care Logic

This is not a bill: $15 for EKG.

Second correspondence, a few days later, and 17 days following incident:

Amount billed: $0
Member rate: $0
Pending or not payable, "A claim that needs more review by us or an amount we did not pay. You may or may not have to pay this. Read the 'Your Claim Remarks' to learn more": $232
Deductible: $0
Coinsurance: $0
Copay: $0

… moving on to Your Claims Up Close:

Emergency Services on ____ [#random code] Amy M. Stubbs [Don't you remember meeting her? Really? Wow.] Refer to Remarks Section, $232.


General Remarks:
(1) You or your spouse may have other insurance that would cover this claim [which is silly because we are your only insurance, and you don't know what the claim is]. Please call or write us to confirm. If you or they [incorrect grammar] have other insurance, please send us:

1. Name, birth date, and member ID of the insured
2. Group name
3. The date coverage began
4. Name, address, and phone number of the other insurance company [because we want this to be on your Google-time, not ours — and what makes you think that our industry has some kind of handy database at its disposal? Sheesh …]
5. Employment status of the insured — actively employed, retired, or on COBRA benefits

This information may be found on the ID card for the other health plan [which does not exist].

We will make our decision within 15 days of getting the information. We'll deny the claim if we do not get this information within 45 days from the day you receive this form [a date which cannot be proven but unless you blog about it, but we have no money to look into that; also, it's confusing, isn't it, 15 days or 30 days after that — or is it really 15 days? Business days or calendar? Ah-ha, you are confused now, aren't you? You are not at all sure how you may or may not preserve your rights!].

For claims sent from Texas: Your claim may remain open if we do not get the information. [Please, do not wonder why that is … we can't just succintly say, "Laws vary by state, you know, the United States of states' rights and non-nationalization of anything means exactly this fact, because that would be inefficient and cause loss of freedom (to move to another state that has slightly different and better regulations)."]

For claims sent from North Carolina: You have 90 days to send us the information. If we don't get it [note, this is regardless of whether you send it or not], the claim will be denied. You will have one year from the date of the denial to give us the information. We will then reconsider your claim. [In other words, we often wait YEARS to get paid, and we seem to be o.k. with that. But, no, that has nothing whatsoever to do with the cost of providing healthcare.]

For NY plans [the state of New York does not need to be spelled out like the other ones]: If we do not get this information in 45 days, we will process the claim with the information we have on file

(2) Your provider may have sent diagnosis codes with your claim. [Soooo, why don't we have them — unclear! Why do you need them — unclear!] You may obtain these codes [again, your time, not ours] and their meanings [b/c such things are by no means standardized — you think this is an organized country or something?] by contacting us [not the hospital — remember we don't  really know what happened to you at the ER, and they can't tell you, either (until later in this letter)] at the number listed at the top of the first page. We will also provide your treatment codes and their meanings, if they do not appear on this statement [which you and I both know, they DON'T]. If you have questions about your diagnosis or your treatment [please, no requests about this statment itself], please contact your provider [not us, even though we just told you to call us to get the codes].


Any suggestions? Obviously, I have to make phone calls. Obviously, I'm not sure it's worth $230 to try.

I didn't mention the two pages after that with each state's Consumer Assistance Program numbers. Are those to help me decipher the bill or to help me pay it?

Also, my policy says I have a co-pay and a deductible. As usual, I just don't understand this system.

And I am pretty sure no one was meant to.

A friend of ours who is about 50 but seems at least a decade younger (and hence is uninsured; a very fit man, mentally and physically) just busted up his ankle on a job site. Going to ER was imperitive, unless he wanted to end up like Jurgis Rudkis and so many others 100 years ago. Perhaps I can provide this poor dear's medical statements for our collective enlightenment at a later date.

Veterinary bills — those make sense!


Hyperblogal said...

Things stopped making sense when MBAs and lawyers took over the world and emphasis shifted from product and customer service to monthly bottom line. I wish you luck in your quest. May Odin smile upon your endeavors of seeking and the consequences pleasing to the purse.

hearmysong said...

Call your Member Services line on your health insurance card. Have the not-bill ready and ask, ask, ask. Explain on the phone that you do not have any supplemental insurance. They might think you still have coverage from your independent policy (prior to working where you currently work). Inform them that that's not true. Try to locate your certificate of coverage to find out what your correct copay and deductible are, and be prepared with that information, if the person on the phone doesn't have them. If you are not satisfied with the person on the phone, ask politely to speak with a manager or supervisor. If you are not satisfied with the response you get, take the person's name (first, try to get last, or representative number). They will usually turn you over to a supervisor. Be polite but firm. The language is ridiculous but standard--not unusual for health care industry forms I've seen. I'm curious what they're investigating. So find out. It might just be a simple phone call. Is there an HR person at work who can help (last resort)?