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Double standard puts patient between a rock and a hard place

Posted by Kristin Baird on November 11th, 2008 • No Comments »

When providers and insurers can’t agree, guess who gets stuck in the middle? The patient. When I’m the one caught in the crossfire between the insurance company and the provider, I often feel overwhelmed, confused and a bit intimidated. If a healthcare professional like me feels this way, how does the 80-year-old veteran on a fixed income feel? You can be assured that they too feel confused and perhaps helpless.

Yesterday, I got my first bill from a physicians group from whom I received care 11 months ago. My appointment had been in December of 2007. I’d needed this specialty consult at the recommendation of my primary care physician. To save time and gas, I scheduled the appointment with the consulting physician through my local community hospital rather than the academic medical center. My company participates in a high deductable health insurance plan and provides an HSA (which I personally like because it makes us all more aware of the costs and our personal investment in healthcare services). Because it was December, my deductable for the year had been met and I should have had no out-of-pocket responsibility for these services. That is, if the provider processes the bill on time.

So, I had my appointment in December of 2007. The appointment went well. The service was great and the provider was not only thorough but friendly and prompt. I scored them with high satisfaction all around. That appointment was long forgotten when, on June 20, 2008, I received a note from my insurance company telling me that the claim was being rejected because it had been submitted to them too late. Six months after an appointment is apparently too late for the insurance company to process a claim, but imagine what the provider’s accounts receivable looks like if this is their standard practice. I have a feeling that they are far above the industry benchmark.

After seeing the claim rejection notice from the insurance company I assumed the matter was closed. No such luck. On November 7th 2008, I received my first bill from the provider telling me that the total is due by the 16th. They can take 11 months to send the bill, but I get one week to pay. Go figure.

Trying to resolve my issue, I turned to the contact information on the bill only to find that the office hours are Monday through Friday 8:00 – 5:00. I also found their financial policy reminding me that anything not covered by insurance is due within 15 days of receiving the statement.
When a patient arrives for care, it is standard practice for him to sign an agreement stating that he understands that even though he has insurance, he is ultimately responsible for the bill. The trusting, insured patient is probably thinking, “No problem, this should be covered.” In my case, knowing that my deductible was met (all $2000 out of my own pocket through my HSA), and knowing that I had a provider that was covered under my preferred provider list, there should have been no issue. But now, through no fault of my own, there is a problem. It never occurred to me that I should have the provider’s medical practice sign an agreement with me stating that I will be responsible for the bill if they will be responsible for timely and thorough claims processing. Now that I think of it, maybe this should be the next trend in consumer-driven healthcare: Have the medical practice sign an agreement that they with be timely with their paperwork in order to avoid unnecessary claim rejection.

Who’s to blame here? We have a patient who pays insurance premiums monthly and puts money into an HSA to cover high deductable and is careful to select providers covered by insurance. We have an insurance company who has an agreement to cover the patient and to accept the provider on the panel. We have a provider who delivered appropriate service but was late in submitting the claim.

Here’s my take: I lived up to my responsibility, now you boys fight it out. Of the three parties involved, I can rest easy knowing I did my part.

Baird Consulting


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