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Thursday, December 08, 2022
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Computers can help us sort through loads of data with the mere push of a button. The wonders of technology are truly a modern blessing. But one single misplaced digit can wreak havoc, and prove very difficult to correct.

Just this past week I found myself helping a man who—not for the first time—got medical bills that he couldn’t sort out. That’s not terribly unusual, as many medical bills are generated in a most confusing manner, and can be difficult to make sense of. But this case was well outside the realm of the routine.

Anthony* received his eighth medical bill in a week for services that should have been wholly covered by his insurance, and where his sole financial responsibility should have been his $35 copayment. These eight bills spanned five weeks of medical services, from different providers, but arrived in quick succession. In every case, his insurance carrier denied the claims because, it claimed, its member Anthony was not the same person as the patient Anthony who received services.

That was news to Anthony, who, to the best of his knowledge, hadn’t been traveling outside his body that whole time.

The ID card he presented was valid, and had been correctly issued. His personal identification was legitimate and had his photo on the front. He had paid his copayment, his checks didn’t bounce, and his credit card was never declined.

However, according to his insurance carrier, his date of birth was one day before it actually took place. All his other documents correctly listed him as having been born on the 22nd, but his insurance was certain that he had been born on the 23rd. Consequently, as the carrier’s customer service agent explained, the person who received services could not be the same person who was covered by the policy.

One would think that the fix was simple. All the carrier had to do was update his personal information, and everything would be just fine. But they wanted proof of identification from “their” Anthony, someone who was born on the 23rd, in order to update the records, and that person did not exist. Nuts!

It took a lot of involvement, from Anthony’s HR department and the carrier’s sales team, to get the whole thing straightened up, and a scant nine weeks later Anthony was a day younger, with the correct date of birth. Problem solved, right?

Alas, no. Now all the claims had to be reprocessed by the insurance carrier, as they had been denied incorrectly. But the carrier’s contracts stated that valid claims had to be submitted by the medical providers within 90 days from the date medical services were rendered, and it was now well past that, so it didn’t want to pay. Never mind that the providers had proof that the carrier had received the claims on time, and never mind that the carrier had messed up in the first place by incorrectly entering Anthony’s birthdate, it considered a deadline a deadline. Period.

The providers, naturally, wanted to get paid, and as they had done nothing wrong they wanted to make this Anthony’s problem. Anthony wanted his insurance to pay, as it was their mistake that had caused this mess in the first place. The carrier didn’t want to listen to anyone.

Happily, everything worked out. By bypassing the layers of bureaucracy, and skipping straight to a member of senior management (thanks to a personal connection Anthony’s sister had with a head honcho at the insurance company), the carrier eventually did reprocess the claims, and the providers were content to patiently let them sort it out.

But the outcome could have been bad for Anthony. He could have been sent to collections by the providers, and they would have had legitimate paperwork with which to enforce their debt claim. And had the balance truly been large and unaffordable for him, his credit could have suffered significant damage.

If one finds themselves in such a situation—where the insurance doesn’t want to pay, and the providers are seeking remuneration from the patient—it is critical, along with taking all the other steps to clear matters up, to either obtain written agreement from the providers that they will not collect on the debt until the insurance situation is resolved, or to set up a payment plan with the providers that will prevent them from sending the account to collections. Payments to the provider can be refunded to the patient when the case is rectified, but damage to one’s credit can be much harder to fix, if at all.

Yossi Faber earned his MBA in healthcare magna cum laude from the joint Mount Sinai School of Medicine—Zicklin School of Business program at CUNY Baruch. He is a member of two healthcare industry-focused networks of expert professionals, and is an invited lecturer at major medical centers and state medical societies. He founded and manages Clean Bill of Health (www.cleanbillofhealth.com), which provides both medical billing services to physicians as well as advocacy services for patients to review and help reduce the burden of their medical bills. Yossi lives in NJ with his wife and children.

By Yossi Faber

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