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Health insurance companies delay so patients have to pay

BY CLAUDIA RICCI For The Sunday Gazette

Claudia Ricci, a former reporter for The Wall Street Journal, teaches journalism and English at the University at Albany. She lives in Spencertown.

    You know something is really, really wrong when you find yourself on a first-name basis with a person in the billing department of your local hospital.
    Donna is the woman I’ve gotten to know in the last few months. She seems to be a lovely and hard-working woman. And she is at least as fed up as I am with the health insurance company I use. Because lately, the insurer keeps bouncing back claim after claim after claim.
    Like me, Donna is growing increasingly certain — and angry — that health insurers are making it more and more difficult for health providers, i.e., hospitals and doctors, to get paid. She is growing convinced, as I am, that insurers have instituted more procedures to guarantee that insurance claims will be delayed, thereby giving the insurance company more time to hold onto money that belongs to somebody else.
    I am, of course, one of the lucky ones. Unlike 47 million decidedly unlucky Americans, I actually have health insurance. And I have what’s considered a very decent plan — the New York state plan, which serves thousands of New York state workers.
But it’s the same sort of decent insurance plan that most Americans have: the kind that doesn’t pay unless you badger them.
PLAYING GAMES
Lately, my insurance company has started to play baseball with my claims. Every time I have a claim, the two parts of my health insurance plan just stand back and take their bases. One insurer takes the claim, throws it up in the air, and then denies it’s their responsibility. Then they toss the ball to the other insurer. The other insurer denies it and tosses it back.
    Just this morning, I had one of these very typical go-rounds with my insurance company, go-rounds that lately have become routine. This one came over a claim submitted for a visit to the hospital emergency room on July 30th of this year, when I needed stitches removed from my head.
    Simple, right?
    Well, no.
    The hospital called Empire, my insurer, in early September and was instructed to send the claim to Blue Cross. The hospital did just that, and Blue Cross paid a small portion of the bill, but denied the bulk of the claim. Empire then instructed the hospital to bill United Health Care, the other half of my insurer.
As instructed, the hospital submitted to United, at which point the claim was denied.
Why? The denial I received explained that “your claim was not submitted within the time frame specified in your plan.”
Hmmm. How curious. How curious, too, that United, on the denial form I received the other day, indicated that the incident occurred on July 30, 2006! Typo? Perhaps. But what a convenient way to delay payment.
I phoned United this morning. The representative I spoke to, a man named Stan, told me that the reason the insurance claim was denied was the hospital’s fault: the hospital, in submitting the claim, never sent United an “explanation of benefits,” that is, United was never formally told why Blue Cross only paid a portion of the bill.
PRESSING THE POINT
    “Ah,” I said to Stan. “So is it my responsibility as the patient to make sure that Blue Cross does what it’s supposed to and sends the explanation of benefits to United?”
    Stan stuttered some response. I kept going.
    “I didn’t realize that it was my job to make sure that the insurance companies do what they are supposed to do, communicate with one another.”
    Stan was taken aback. I think he was shocked that I was dissing his company.
    “Your provider just isn’t following the rules,” he huffed.
    “Ah, yes,” I said. “I guess the hospital, after all these years, and after all these millions of claims they’ve submitted to insurers, just doesn’t know the rules anymore.”
    “Stan,” I went on, “I know it isn’t your fault, because you are just an employee. But you should know that there are a whole lot of us out here who are just furious and fed up with the insurance companies for routinely denying and delaying claims. If I were really sick, God forbid, I wouldn’t have the energy to phone the hospital, or you folks, like I did this morning, tracking down claims to make sure they get paid.”
    Stan repeated himself, saying it was the hospital’s fault for not following correct procedures.
    Sure thing, Stan.
    So what does my friend Donna back at the hospital billing department have to say?
    She says that many people just don’t bother to track down claim denials, because they are too busy, or too sick, or because the denial trail is way too complex, and way too taxing. “People give up and just pay the hospital themselves,” she said.
WEARING US DOWN
    Ah yes. I guess in the end this is what it all comes down to, doesn’t it? Health insurance companies institute delaying tactics so effectively that they wear us all down. We get so fed up we just pay the bills ourselves.
    Lovely system.
    We’ve got to have something better than this. A system that works. If we as a nation can spend a whopping $700 billion to bail out Wall Street’s self-inflicted woes, we certainly can find $60 billion, or whatever it takes, to cure our health care system. Can’t we? Because health insurance problems like this are killing us. And killing our economy too. Imagine what it would be like to have a health care system where everyone was covered. And where claims were paid, as they should be, in a timely manner. Can you imagine?