by Marianne Mattera
“I Hate [Insert Health Insurer Here]”
Not long ago I sent an e-mail with those headline words as the subject line — I have withheld the name of the insurer to protect . . . , well, myself.
A combination of circumstances has led to massive hassles costing me what is easily 100 hours of checking, rechecking, e-mailing, and phone calling over the last 3 months. And still the explanation of benefits forms don’t provide the correct out-of-pocket figure and, I’m told, never will. And I’ve been told that the responsibility for figuring out where things stand between me, my healthcare providers, the insurer, and the HRA (that’s the people who administer the health reimbursement account that goes with the high deductible plan I have) is mine.
Now, I’m not one to shy away from responsibility. And I consider myself fairly savvy about health matters and insurance coverage. I spent more than 17 years of my healthcare journalism career on a magazine devoted to physician practice management. You don’t put in that amount of time without learning a thing or two about health insurance.
Yet I readily admit I’m hard put to figure out what’s been done to whom. And a good part of the reason is that the insurers and the HRA do not report services or payments — mine or theirs — using the same terminology. Nor do they always reflect the terminology used on the billing forms my doctors use.
I’ve got to believe that simplification would help.
Other people believe the same thing. We published an article last week about a study that detailed the monetary savings that could accrue by using a standardized claim form and a single set of submission and payment rules for all health plans. The number: $7 billion. And that doesn’t count the psychic savings.
Two sentences in that report stood out in my mind: “For non-Medicare payers, 12.6% of billed charges were denied on initial submission. After appeals, 81% of initial denials were eventually paid.”
Think of all the wasted work implied by those numbers — for all parties in the equation.
Physicians and their staffs blame the insurers, the insurers blame the physicians (and have I heard a lot of that in the past couple months!), and the patients scratch their heads, try to play go-between, or sit back and wait for the other two parties to work things out before laying out any more than the copay. Or, they pay the bills only to get refund checks from the physicians when the insurers eventually fork over what’s owed.
Now, it can be argued, and rightly so, that physicians should just back out of the whole process. When I first started my working life, I paid the doctor, and then I submitted bills to my insurer. Recouping from the insurer was my problem; I was the one who had the contract with the insurer.
I’m not sure when that changed, or why. Medicare, maybe? When usual-and-customary reared its ugly head? Certainly when HMOs and PPOs made the scene.
But I do distinctly remember discussions in the early to mid ’70s about how the Superbill would streamline the billing (and thus the reimbursement) process.
Guess it didn’t work. And I guess I’m not convinced that these new calls for a standardized claim form will save all those billions, but I sure do believe that all parties concerned need to get on the same page — and that’s what the “single set of submission and payment rules” would accomplish.
Whether that uniformity can be attained with multiple insurers in the picture, or whether we’ll have to migrate toward a single-payer system, I don’t know. I do know, though, that I’m tired of trying to straighten out the mess that was created by people at the [insert health insurer here] who misread an insurance contract and started the process that’s occupied nearly 30% of my waking weekend hours for the last three months.
Marianne Mattera is Managing Editor at MedPage Today and blogs at In Other Words, the MedPage Today staff blog.
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