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Nobody is more frustrated with America’s broken insurance system than healthcare providers

Posted Apr 30 2010 8:11pm

Nobody is more frustrated with America’s broken insurance system than healthcare providers who are prevented from simply helping patients. 

Just consider the environment we get to work in.  There are more than 1400 insurance companies, all who constantly change their medical policies and reimbursements without fully notifying their members or providers.  Then we have the many plans who take their sweet time paying a legitimate claim.

Every situation is different, but after successfully working with over 17,000 (yes, seventeen-thousand!) satisfied patients, we have identified a few tips for dealing with difficult insurance companies:

Please don’t shoot the messenger.
Unfortunately, some patients think they can get their insurance company to do what they want by beating up on the dedicated healthcare provider caught in the middle of a battle between the patient and their insurance company.  The simple truth is, health providers have less power over insurance companies than patients.

No good deed goes unpunished.
Healthcare providers often try to help the patient by getting an estimate of their insurance coverage and to identify probable out-of-pocket expenses.  We often spend hours – unpaid – trying to help patients get their insurance reimbursement.  But the payors always tell us that the patient’s status they give us is preliminary and may not be accurate.  It’s no wonder that information we pass on to patients often comes back to haunt us.

Make sure who is providing coverage.
To save money, many employers are self-insured and merely hire an insurance company to handle paperwork.  Accordingly, your problem may not be with the insurance company, but the Human Resources Department of your company that has established the payment rules.

Complain to the Insurance Company CEO and Chief Medical Officer.
Most insurance companies have a senior-level “resolution” team to review and investigate issues.  If you do your homework and reach the right people, you might get the answers you are looking for.

Complain to the Government.
No, seriously.  The Government says they are here to help.  The State of California actually has a way for you to complain and force an independent review of your argument with a health insurer.  The process actually sometimes works (but, see next tip).

It’s good to believe you are right.  It’s better to actually be right.
Time and time again, some patients are absolutely convinced the insurance company is wrong; only to later discover the patient has limited coverage, no coverage, a high-deductible, a high out-of-pocket expense, or many other problems that the patient wasn’t aware of until after they filed a claim.

Be nice and watch your tone.
Sure you are frustrated, but if you make no attempt to be pleasant or polite, no one will want to help you.  People in the healthcare industry don’t wake up every day just to make the lives of their patients miserable.  They are equally frustrated working in a broken healthcare system and a patient being abusive to others isn’t going to encourage anyone to make an effort on your behalf.

Generally speaking, generalizations may not always be accurate.
In the smoke-and-mirrors world of health insurance, the experience of one patient and how they are treated (or, more accurately, mistreated) is not going to be the same experience of other patients.  The problems of one patient is not always the same as others.

Health Insurance has got to change.
We agree with everyone who complains about how badly they are being treated by their insurance company.  Even those patients who complain bitterly about not getting paid, then finally get paid by the very insurance company they are complaining about. 

We understand.
We absolutely understand that the effort it takes to battle a health insurer when it refuses to cover certain treatments is both aggravating and time-consuming.  We also have come to recognize there is a limit as to what we, or any healthcare provider, can do for patients in difficult and complex coverage and reimbursement situations.

When you’re in the middle, you get hit from both directions.
We get hit by patients on one side who complain we aren’t doing enough to get them covered for a service.  And we get hit by insurance companies on the other side who tell us they won’t pay us for what we did for the patient.  It’s not easy being a healthcare provider.

In summary…
We have 17,000+ satisfied, kind and considerate patient success stories. We can’t help everyone, but maybe the above tips can help you.  Are there others out there who also have been mistreated by insurance companies?  I suspect we are not alone.

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