An Open Letter for Patients in America's Healthcare System

trudlebug · Jan 18, 2014

With the Affordable Care Act causing so many changes and questions in healthcare, more people are asking questions about what it means to them. Many people do not know how insurance plans decide how to pay for medical care. I would like to give you a brief overview of how the process works, so you can use that knowledge for future decisions you may need to make regarding your healthcare coverage.

The first thing to know is the insurance plan can decide what they will or will not cover. If it is not a covered benefit, they will not pay. This is where the Affordable Care Act is causing changes in insurance plans. There are some things they are no longer allowed to omit. If the costs for these benefits are higher than the company feels they can pay, they may decide not to provide insurance coverage for their employees. These are the people who will need to go through the health care exchanges that have been discussed in the news.

Generally speaking, the process works like this: Hospitals have nurses or social work/case managers (often known as the Utilization Management or Review Department) who review the medical information and send it to the insurance company. Doctors often employ someone that specializes in billing, coding and making insurance claims. Insurance companies have nurses who review the claims, and if it is for a covered benefit, and they meet criteria^*, the claims are approved. If they do not meet criteria, or are questionable in some way, those cases are then reviewed by a physician who decides whether or not the claim is appropriate. If it is not a covered benefit, the insurance plan will not pay.

I am a nurse reviewer at an insurance provider. I previously worked in Medicare/Medicaid. Now I am working for a third party review company for businesses that do not purchase one of the big-name insurances, but fund their own insurance for their employees (self-funded insurance plans). I have experience in multiple types of plans, and have reviewed thousands of hospital cases.

Most of these insurance company nurses and doctors are looking out for the patient's best interest. I have fought with hospitals to track down information, or even just to get them to send information so we can review and approve cases. I have searched for providers and facilities that are in network, and arranged for special contracts with those that are not, in order to save the patients money. I have even argued with the "business" people at our company to get claims paid. I would say we approve most claims without any problem. Claims are often denied due to lack of information or improper coding that does not match the diagnosis or procedure. When these are corrected, payment is made. It is rare to get a denial when we receive all the proper information. One of the biggest problems I have run into is the hospital often does not send the correct information, and sometimes does not send ANY information to the insurance company.

Also, many insurance companies have contracts with "in-network" providers that prevent extra charges being passed on to the patient. Look at your individual plan coverage to know what your co-pay and deductible payments are, and be sure you do not pay more than you need to.

I worked in many different hospitals before becoming an insurance review nurse. I have seen the process from both sides. People have to be an active participant in their care for themselves and their loved ones. My recommendation is "Be a good consumer and a partner in your healthcare". - ask questions and read the details of your insurance plan. Talk to your doctor and insurance company and find out what is covered before any elective procedures. And do not pay any bills that seem "wrong" without calling your insurance provider or doctor first. They can review the claims, deductibles and so on for you to make sure you are not getting over-billed.

My suggestion to anyone who is told by a doctor or hospital "your insurance company denied this" - Call the insurance company and find out why! It could be that they never received the request. It could be a clerical error - a mistake in a diagnosis or procedure code will stop a claim payment. Maybe the fax just did not go through. Maybe the nurse reviewer spent days chasing down information, and did not get a response from the hospital. Maybe the insurance company really is one of *those* companies that tries to deny everything. Maybe the planets were aligned in just the right (or wrong) way and all of the above happened. If you do not want to call the insurance company, ask your doctor, the office staff or billing office where you were seen, but ask someone.

I cannot tell you what all insurance companies or hospitals do. But I have spoken with many people involved in both patient care and claims. Most of these individuals want what is best for their patients - those on "both sides". And remember, it is easy to blame the nameless, faceless insurance company. But the companies employ people, and people are human. We have families, friends, ideals, ethics, and beliefs. We care, we love, we learn and we make mistakes.

So get involved and ask questions whenever you can. Take control of your healthcare. Try to use your insurance company as part of your healthcare team, not as the opposition**.

I have a name, and a face.

And I do care.

"Trudlebug, RN" nurse reviewer for a great insurance company.

*review criteria - should be evidence based and peer-reviewed standards of care. The hospitals can also use the criteria to assist them in planning care.

(**Unless your insurance company really is one of *those* companies - then educate yourself and take them on! But again - take control of your healthcare!)