Monday, July 14, 2008

Constant battle

Medical insurance issues and authorizations are my thing. It's what I do. It's been at least part of my job for more than 10 years now. I get journals and magazines and do seminars and continuing education in the field.

Even with, and maybe due to, this expertise, I get SO frustrated at how wrong some of the practices we deal with in Braska's care can get what should be a simple process. How in the world do parents do it that don't know how the system works?!? When they get an EOB (the explanation of benefits from the insurance that tells you what they pay and what they won't for a particular visit or service), and it says something is denied, do they just pay it and suffer the economic setback or do they know that there are any of 15 things that could be wrong causing that denial to be incorrect?

I've spent the morning calling our case manager at the insurance--who is little help, unlike the previous ones we've had--getting no pertinent info other than what I was telling HER. I had to tell HER how it should work and what her next step should be. Then I called the therapy location to inform THEM how to bill properly so that they will get paid. Now, mind you, I've done this at LEAST 2 times before for both these entities. I always try to be very nice when I deal with people on the phone that I know I'll be encountering again, so as not to start a bad rapport with them. But this time it was business to the point. Here's why it's denied. Here's what you did wrong. Here's how to fix it. Here's who to contact. Here's what to do next. And then I require them to call me when it's done correctly so I can follow up and make sure.

Sure, I've been a boss in this position for years, and it's not hard for me to take the demanding position, but when it's been in and out their ears with no good result, it's time to make things clear. I can recite diagnosis codes by the hundreds and I can pretty much tell you what things will be covered and what won't for several major insurances. I'm thankful I have this background in our situation, but so many of you don't! How in the world do you do it?!? I'd lose my mind... I'm close already!

Ok, I don't really vent often, but I'm just so tired of doing the work of all these other people who I'm paying to do their job! I'm very thankful for insurance, and I know the system CAN work when people will just pay attention and learn what they need to know. I can't train everyone myself! :o)


  1. What do the rest of us do. We either ask questions and get 0 results and then pay because it seems that is what you have to do, just pay because it says that it is not covered so you figure it is not covered. I think I will put you on speed dial when we have new insurance to deal with. I loath changes of that matter. So vent away:-)

  2. I think most people can understand the frustration. The worst is when you call to ask if it's covered before it happens, and they say "yes" then you find out millions of phone calls later it never really was covered. You'd think things would be more 'user friendly'! You are lucky to have the background you do. Oh and by the way...Congrats on the house too!
    ~Marci U.

  3. Love the new picture for Braska's link. She's the second cutest kid I've ever seen. :)

  4. You'd best be careful; people will be wanting to hire you for their personal insurance consultant. Now that's an idea: it would make you money and save them money :o)

  5. YES! You read my mind. I wish I had your background and tenacity in dealing with these people. Sometimes we end up paying--sometimes we've even gone into collections for things that should have been paid for. it's incredibly frustrating dealing with spasticity clinics, neuros, pt, ot and any other of a dozen things.

    Ok, I'd better step off my soap box or I could be here all day.

  6. OOOOHHHH How about when I called Inpersonal Care for the very first time after Larkin was diagnoised. They were rejecting all of our claims. I - a grieving mother who had just given birth weeks prior - and I quote "We don't cover Down syndrome, you need to go get Medicaid or Medicare for her" Girly girl - you know me. I don't shrink from anything. I SAID OK AND HUNG UP. ME! Then I sat there for about 20 minutes and went "what the hell?" called them back and said here are two words you need to write down, Law Suit. (yes I know it's typically one word) I had to fight with Inpersonal Care for quite and while and still do off and on and they are her SECONDARY provider. So if you use "Personal Care" you may want to consider getting your PHD in Hamsterology cause they like to run you around the wheel.

  7. Y'know, I think that becoming a personal consultant might be a really marketable idea. Not that you have nothing else going on, but file that one away for later...I think you could do something with it. I would have (and still would, honestly) been thrilled to have someone to tell me exactly what to do. Especially over the first few months or year.


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