Medical Pinball!by Sue Meadows, Health Benefits Advisormedicallife@uskoa.com
Why was your medical insurance claim denied? It can be a mystery. More often, common sense tells you that your rejection letter is an error. Surely we think, "Policies insure for the medical costs of a child's broken arm, don't they? What insurance policy
wouldn't?" Common sense isn't often involved with medical claims, though. Though a broken arm not being covered may seem a reach, later on I'll give you an example of how it sometimes happens . . .
You're bill for medical services is, of course, based on what was done, when, and who provided the service. Your eligibility for insurance coverage is determined by who you are, what plan covers you and your family, and what, when, who, and how many provided your medical services. Really important is how the insurance plan’s terms and definitions apply to it all, and whether another “payer” might be responsible for any any of your charges.
Your medical care and the claim denial or payment notice you finally see weeks or months later has been bounced around by a largely automated process, very much like a pinball game. It takes a bit of knowledge for you to win the game and hear those happily ringing bells . Unlike the almost complete luck of a pinball game outcome, though, your knowledge of the health insurance game can give you a lot more leverage. So, let's see how to jiggle the insurance pinball machine a bit.
Pinball Wizardry. Your health insurance pinball machine ‘wins’ if it rejects any of your family's medical claims that don't navigate all its mazes. In the game, many legitimate claims are rejected. These rejections then need to be reviewed by a "claims representative." and then pursued by you, the patient, to get reversed. You can simplify the game by making certain that the medical providers you see and the treatments you get are covered by your plan, and have all the needed documentation to prove it. Often, like pinball's crazy universe, that’s not enough, but it does help a lot. Computerized "insurance claims management systems" sort medical bills and may reject all or part of your claims that do not match their rules, even the smallest of them.
So, your pinball game starts when you pay your “quarter” (your insurance premium), or you see a doctor, or visit an emergency room, etc. Two balls queue up, ready to go. One ball is you; the other is the medical care provider. The pinball game itself, remember, is your insurance plan's rules. On your first shot up the chute your ball tries to pass through patient identification: name, date of birth, social security number, address, and health plan identification number. These are keys to the health plan’s record of your eligibility. No match found for you in the health plan's records associated with the claim? Bumper collision! Claim denied.
How about if you, the patient, is not the actual health plan “subscriber” – the one who signed up for and pays premiums for the insurance? Let's say it's your fourteen year old son who has just badly sprained an elbow by raising his hand in class too vigorously to answer physics questions. He shows up at the emergency room, and your subscriber identification information and the relationship between you must match. Also, the subscriber (you) and the patient (your son) must also fit the plan rules. A failure to match you two can be a result of
- an error entering data, or timing (perhaps your son is not yet entered in the system),
- a confusion of two people with the same name and the same city,
- or a surprising number of other factors. In any event, if the identification fails, the ball rolls back to the bottom and moves into what they like to call the “exception queue.” But the practical effect . . . Claim denied.
Suppose you get a confirmed identification match, the system then checks for other plan coverage. Are you also covered by another plan and is that other plan your primary one? If not, then the ball stays in play. If you are covered by any other plan(s) though, well then, you're catapulted into another maze that demands extra dexterity to navigate, and practically speaking, it adds time to your entire claim review.
So, here we go. Date of service as given on the claim is matched against your identification data. Were you enrolled at the time of your medical care? If yes, then the system moves on to the health care provider. If the provider wasn't enrolled (under contract) then, whaddya know: Claim denied!
But the game will keep your claim in play if the provider is qualified according to their rules for services. So, now flip your ball up the chute for your provider, for example, your doctor. Your plan may not cover chiropractors, dentists, physical therapists, social workers, home health assistants, or other professionals. Or it may cover some of them only under some circumstances. That's right. Another maze, another possibility for . . . Claim denied.
If the type of provider is covered, though, then your provider will be compared against the database of plan-approved or member providers. Some plans, such as managed care, permit only certain providers to be used, or . . . Claim denied. Other plans pay different rates depending on their contract with the health care provider. If the provider is not a plan member or plan-approved, those plans pay a smaller percentage of your claim. Guess who gets to pay the difference.
Rolling and Bumping. So, rolling along to the next bunch of pinball bumpers: "the valley of when," when services were given. Date of service is a key to sorting the charges, even after you earn a pass on your plan enrollment at the time of service. If, whether accidental or not, there are apparent duplicate claims – same date of service, same treatment . . . Claim denied.
Next bumper: the health insurance plan’s system then looks at the diagnosis and service or treatment given. Usually coded, the service provided (office visit, immunization, MRI) must match the date, diagnosis, and provider. So much can go wrong. This is a surprisingly common source of . . . Claim denied.
For example, is your medical procedure / item / service covered under the plan on the date of service? Is it a duplicate charge? Did it meet special terms of the plan (required referral, care plan, limitation on number of treatments)? Is the code valid? Does the code correspond with the diagnosis? Was the treatment provided in a facility the plan covers? Lots of bumpers. Lots of bumps. If one of these is a ‘no’ . . . Claim denied.
Complicated Enough For You? Here's how complicated it can get. Fasten seat belts. Have an aspirin. Remember the hypothetical at the beginning of this article about insurance coverage of a teenager's broken arm? The diagnosis code pushes his ball into a new area for what's called the procedure code maze with curves and walls shaped by his age, gender, and the diagnosis itself. The teen's family insurance plan may not cover some treatments for that diagnosis (broken arm) at all. Why? For example, let's say that your plan normally does cover a broken arm. That diagnosis has its own code. Well, the treatment for the arm has its own codes as well, these are the procedure codes. To add even more complexity (sorry), there is yet another code, oddly named the reason code. So, here's where it gets dicey, the “reason code” can - through insurance plan “magic” - modify the diagnosis/treatment codes, and his family's health plan might not cover any treatment for the teen's broken arm if the reason (reason code) he sustained the injury is, for example, a motor vehicle accident. This is as common as it is infuriating, and the result, his ball hits a lot of walls, multiple bumpers, and a broken arm, one of the most common of youthful injuries . . . winds up . . . Claim denied.
Finally, if you've navigated the game so far and still have a ball in play, then the plan asks how about the provider's fee? Most plans have a range of fees for medical services that are calculated to be “usual, reasonable and customary” and pay part or all of that amount after your deductible is met and after your copay is taken out. If the provider is covered by the plan, that provider has agreed in advance to accept the insurance company's definition of “reasonable and customary fee.” You are often responsible for some part of that amount, but it's less than the full cost the provider actually charges.
The fees charged by providers who do not accept the insurance plan can be astounding if you're not prepared for it. A lab test to monitor diabetes, for example, can cost well over $400 before insurance discounting. And those tests should be repeated three times per year at a minimum. After discounting, with a lab that contracts with the health insurance plan, the fees may be less than $50. So the claim may be approved, but not in full.
You've probably already been in a pinball game with your health insurer? If you won, along the way your headaches, heartaches, and family financial distress left their marks. And that's if you actually won. I hope my article has alerted you to a sad fact: even if you “win,” you may not have won completely. Your “win” may have stuck your family with medical bills that you really should not have to pay.
I hope this article opens up to you some of the tricks and perfectly legal sleight-of-hand that these companies use to limit their payouts. And how's this for a closing kicker? Sometimes claims are paid and later on the payment is rescinded. I know of no self-respecting pinball machine that does that!
Contact me directly anytime at
medicallife@uskoa.com
for advice about your health insurance problems,
or questions about your health insurance choices or present plan.
Note that I am not financially associated, or in a consulting capacity
with any healthcare plan, health insurer, or health care provider.
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