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Helped Patient Battle Health Plan and Won!Sunday, Jul 5 2009 

Posted Nov 04 2009 10:05pm

Just about a week ago, I received a call from a patient who was extremely upset that she was being billed $1,400.00 by the imaging facility for a CT scan after we told her that she did not need a prior authorization from her insurance company.  Typically, this is one of those things that it’s our word against the insurance company and, historically, the insurance company seems to always win.  I guess the axiom “he who holds the money has the power” applies in this kind of situation.  The insurance company insisted that they did not have a record of our phone call to them and that they would never have told us that this patient did not need a prior authorization for the CT scan.  The patient was irate and understandably so…especially with the economy the way it is.  As a goodwill gesture and to keep peace with the patient, I would have accepted the responsibility and paid for the scan and our office would be out the money.

But…we voice record all our incoming and outgoing telephone calls using a system called Talkument.  I have all of the staff and physicians trained on what information is helpful to me when I need to investigate a telephone conversation.  In this case, I pulled the patient’s chart and the medical assistant wrote a note stating that she called the health plan on 5/23/09 at 3:13 pm and found out that no prior authorization was needed and that she talked with Ann.  I knew my medical assistant’s extension and searched based on the information that I had, and viola, I found the four minute telephone conversation between my medical assistant and the health plan representative, Ann, who said that the patient did not need a prior authorization for the CT scan!

I had a three way conference call between the patient, myself and the health plan where I played the recording for them.  The patient was ecstatic!  I had to play this information a couple of levels up the ladder and was still told that someone would have to get back to me (quite frankly, I don’t think they were ready to address the fact that the doctor’s office actually had recorded them!  Uh oh!  They were caught!)

About a week later, the health plan representative called me and stated that they would cover the cost of this CT scan “this one time”.  She still did not want to take responsibility for her company giving inaccurate information.  She made it sound like we doctored up the recording…even though we have caller ID that had the health plan’s toll-free number and the first two minutes of the recording was the automated system that announces the health plan name.  I was even told by the rep that the person with whom my medical assistant had talked with, Ann, was not an employee of this health plan.  I love the lack of accountability!

Defensive medicine is taking on a new definition.  Besides the Internet, the next best resource I have in my office is the voice documentation system for phone call recording!  The system has aided me with staffing issues, patient issues and now insurance issues.  It has definitely paid for itself in protecting my physicians and our office from lying and deceit.

7 Responses »

 

Just about a week ago, I received a call from a patient who was extremely upset that she was being billed $1,400.00 by the imaging facility for a CT scan after we told her that she did not need a prior authorization from her insurance company.  Typically, this is one of those things that it’s our word against the insurance company and, historically, the insurance company seems to always win.  I guess the axiom “he who holds the money has the power” applies in this kind of situation.  The insurance company insisted that they did not have a record of our phone call to them and that they would never have told us that this patient did not need a prior authorization for the CT scan.  The patient was irate and understandably so…especially with the economy the way it is.  As a goodwill gesture and to keep peace with the patient, I would have accepted the responsibility and paid for the scan and our office would be out the money.

But…we voice record all our incoming and outgoing telephone calls using a system called Talkument.  I have all of the staff and physicians trained on what information is helpful to me when I need to investigate a telephone conversation.  In this case, I pulled the patient’s chart and the medical assistant wrote a note stating that she called the health plan on 5/23/09 at 3:13 pm and found out that no prior authorization was needed and that she talked with Ann.  I knew my medical assistant’s extension and searched based on the information that I had, and viola, I found the four minute telephone conversation between my medical assistant and the health plan representative, Ann, who said that the patient did not need a prior authorization for the CT scan!

I had a three way conference call between the patient, myself and the health plan where I played the recording for them.  The patient was ecstatic!  I had to play this information a couple of levels up the ladder and was still told that someone would have to get back to me (quite frankly, I don’t think they were ready to address the fact that the doctor’s office actually had recorded them!  Uh oh!  They were caught!)

About a week later, the health plan representative called me and stated that they would cover the cost of this CT scan “this one time”.  She still did not want to take responsibility for her company giving inaccurate information.  She made it sound like we doctored up the recording…even though we have caller ID that had the health plan’s toll-free number and the first two minutes of the recording was the automated system that announces the health plan name.  I was even told by the rep that the person with whom my medical assistant had talked with, Ann, was not an employee of this health plan.  I love the lack of accountability!

Defensive medicine is taking on a new definition.  Besides the Internet, the next best resource I have in my office is the voice documentation system for phone call recording!  The system has aided me with staffing issues, patient issues and now insurance issues.  It has definitely paid for itself in protecting my physicians and our office from lying and deceit.

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