I have private insurance through my work. I worked very hard to get a physician to write a letter to my insurance company for me to receive a prior authorization to seek out-of-network care to get a second opinion, inclusive of further testing. Despite the prior authorization, my insurance denied payment for $12,000 of tests and visits that they authorized prior to my appointments. Phone calls to the insurance company resulted in a verbal commitment to fix the problem. Only a couple thousand dollars’ worth of claims were paid as a result of the phone calls. It’s taken me countless messages using the patient portal to spoon-feed both the insurance company and the out-of-network provider links between visit numbers, claim numbers, and prior authorization numbers to see that these claims got paid AND got applied to my existing bill as opposed to any future care. My bill is currently down to less than $100 but I’m still working to get it to $0.
My favorite example is that the insurance company has one code for a blood test yet the provider has one code to draw the blood and a second code to do the lab work. Because of this, only the cost of the lab work was covered
Short version - coding error at the radiologist caused me to be billed for my screening mammogram (a covered procedure under ACA). Insurance company was opaque, radiologist told me it was not coded as a screening procedure, that my PCP must have put the wrong words on the order for the mammogram. PCP's assistant spent her time proving this was not so, finally radiologist corrected their coding. Not even a "sorry about that from radiologist. Took 2mos elapsed time. This was an "easy" one. I've said in other cases, every seriously ill or elderly person needs someone to deal with their medical billing, it's ridiculous.
I've been back in the US since June, after teaching at a public uni in Thailand for the past five years. Today, I spent over three hours trying to book an appointment for something my primary doctor recommended two weeks ago, and that I've made multiple prior attempts to compete. I haven't kept track, but I know I've killed several hours over the past two weeks trying to book this. And while I still don't have it booked, today I made what felt like meaningful progress.
In Thailand, I would go to my local hospital and sign in to see a GP and wait my turn (usually 20-45 minutes). They'd give me a checkup and send me on for a specialist as needed. I might then wait another hour or so to see the specialist. Each time I needed to see a specialist, it happened in the same day as the GP walk-in visit.
So I'm three weeks into the journey here (including the wait from scheduling the initial appointment), and I don't even have the specialist visit scheduled. Did I mention that I never paid for care there?
This is terrific! I have an article in the Harvard Law & Policy Review that gets into the "why" and "so what" questions--why are these burdens so bad and what do we do about it? Your piece ends by focusing on providers, which may be right, but I focus on insurers. Specifically, I trace excess health burdens to failures in the insurance market and suggests systemic reforms to that market to address them. For example, I suggest that insurers should presumptively be responsible for all billing and collection relating to their own enrollees (even of costs that are the patient's responsibility)--rather than have 10 different providers sending bills, you'd have one insurer. And doctors/hospitals would not be put in the awkward role of bill collectors anymore. Of course there are complications, and there are also more subtle, immediately achievable reforms. If you're interested please take a look! https://harvardlpr.com/wp-content/uploads/sites/20/2019/07/Lawrence.pdf
I have private insurance through my work. I worked very hard to get a physician to write a letter to my insurance company for me to receive a prior authorization to seek out-of-network care to get a second opinion, inclusive of further testing. Despite the prior authorization, my insurance denied payment for $12,000 of tests and visits that they authorized prior to my appointments. Phone calls to the insurance company resulted in a verbal commitment to fix the problem. Only a couple thousand dollars’ worth of claims were paid as a result of the phone calls. It’s taken me countless messages using the patient portal to spoon-feed both the insurance company and the out-of-network provider links between visit numbers, claim numbers, and prior authorization numbers to see that these claims got paid AND got applied to my existing bill as opposed to any future care. My bill is currently down to less than $100 but I’m still working to get it to $0.
My favorite example is that the insurance company has one code for a blood test yet the provider has one code to draw the blood and a second code to do the lab work. Because of this, only the cost of the lab work was covered
Short version - coding error at the radiologist caused me to be billed for my screening mammogram (a covered procedure under ACA). Insurance company was opaque, radiologist told me it was not coded as a screening procedure, that my PCP must have put the wrong words on the order for the mammogram. PCP's assistant spent her time proving this was not so, finally radiologist corrected their coding. Not even a "sorry about that from radiologist. Took 2mos elapsed time. This was an "easy" one. I've said in other cases, every seriously ill or elderly person needs someone to deal with their medical billing, it's ridiculous.
I've been back in the US since June, after teaching at a public uni in Thailand for the past five years. Today, I spent over three hours trying to book an appointment for something my primary doctor recommended two weeks ago, and that I've made multiple prior attempts to compete. I haven't kept track, but I know I've killed several hours over the past two weeks trying to book this. And while I still don't have it booked, today I made what felt like meaningful progress.
In Thailand, I would go to my local hospital and sign in to see a GP and wait my turn (usually 20-45 minutes). They'd give me a checkup and send me on for a specialist as needed. I might then wait another hour or so to see the specialist. Each time I needed to see a specialist, it happened in the same day as the GP walk-in visit.
So I'm three weeks into the journey here (including the wait from scheduling the initial appointment), and I don't even have the specialist visit scheduled. Did I mention that I never paid for care there?
This is terrific! I have an article in the Harvard Law & Policy Review that gets into the "why" and "so what" questions--why are these burdens so bad and what do we do about it? Your piece ends by focusing on providers, which may be right, but I focus on insurers. Specifically, I trace excess health burdens to failures in the insurance market and suggests systemic reforms to that market to address them. For example, I suggest that insurers should presumptively be responsible for all billing and collection relating to their own enrollees (even of costs that are the patient's responsibility)--rather than have 10 different providers sending bills, you'd have one insurer. And doctors/hospitals would not be put in the awkward role of bill collectors anymore. Of course there are complications, and there are also more subtle, immediately achievable reforms. If you're interested please take a look! https://harvardlpr.com/wp-content/uploads/sites/20/2019/07/Lawrence.pdf