“Denied”

When I expressed interest in trying to tackle some local aspect of the health care debate, a friend suggested I talk to Phyllis Benson about her experience with Humana. It wasn’t easy calling a stranger to talk about their lymphoma…and then asking them to talk about it on camera. But Phyllis was a sport and we both agreed that the message was an important one.

Phyllis is one of the warmest people I’ve ever met. She’s genuinely nice…and brutally honest!

You could only hear a piece of her story (because we have time restrictions) but I’ll try to explain more here…

The denied M.R.I. claim was just the start of her battle with Humana. It was also her first major learning experience with a insurance company…and her first victory against them.

She didn’t hear from Humana that her claim had been denied…she heard from New Hanover Regional Medical Center. They sent her a letter that told her that she was responsible for the +$2,000 bill. Phyllis lives on Social Security and there was no way that she could afford that tab. Plus, she was sure that she was covered for the procedure.

Personally, I would have been going ballistic. But Phyllis sat down (calmly) and wrote a letter to Humana explaining the situation. I have a copy of that letter. Its very polite…but very straightforward.

Humana responded with a letter saying….that she would have to wait…to hear a response. When they DID respond, they said that she had waited TOO LONG to send in her appeal. That might have been true…but remember…there was a long delay in her even finding OUT about the denial because she wasn’t contacted by Humana directly.

She continued to write to both the hospital and Humana.

Bill collectors started showing up at her door.

Humana denied the claim three times. On the fourth appeal, they wrote her an apology letter to say that it had all been a processing error and that her check was in the mail.

She says, “Its a shame to have to fight the insurance companies and hospitals after you’ve been fighting a disease.”

That fight continued…and so did her winning streak.

“If they know that you don’t give up and you’re gonna fight ’em, they’ll usually pay it and it’s terrible to have to do that and I know there’s a lot of people out there that don’t know how…but you can do it.” -Phyllis

Phyllis has gotten creative with the her costs and her dealings with her Humana.  Since she has to pay each time her port-a-cath (PAC) is cleaned (a small medical appliance that attaches a port to a vein near the collar bone to deliver chemo)…she delays her cleaning to every 3rd month, instead of every month. She also orders a higher dosage medicine and cuts them in half.

Its these kinds of “shortcuts” that have hospitals concerned…

Mary Ellen Bonczek is the Chief Nurse Executive at New Hanover Regional Medical Center that you saw in the story. She says shortcuts and delays in treatment are what have people arriving at her doorstep sicker than they would have been if they had sought out care at the appropriate time.

That’s not to say that she’s not sympathetic to what people are dealing with on the insurance side of the equation..

 She says, “I see people AFRAID to NOT have insurance. As the consumer, you think you’re paying a premium to get something and then you get denied and you’re like ‘WHAT? What the heck was THAT?! What happened?!'”

If insurance companies are denying more claims, its not just consumers that are hurting…it also means the hospital is losing revenue that they depend on. So at NHRMC, they have created an entire team of nurses and one physician who work on just insurance claims. That effort helps the hospital but it also helps their patients get coverage.

“It is a full-time job – to manage and advocate for the patient completely…We have had to add that level of DAILY critique to make sure that we stay on top of our revenue.”

 You, the consumer, luckily do NOT need to critique your insurance daily but that doesn’t mean you don’t have to know and understand it. Remember, this is something YOU bought and it comes with a hefty booklet of information outlining everything you are and are NOT covered for…

Mary Ellen advises, “Its important for the community and the consumer to talk to their insurance company to know it and to question it. So many people just accept it and they don’t question it. They don’t ask, they don’t call, they don’t follow up. They just say “Oh no.”

Who can blame them? Have you ever tried to READ one of those booklets? Luckily, every insurance company has a hotline.  YES, it is a pain to press all those numbers and negotiate all those channels…but you CAN find humans at the other end who should be able to clarify your policy.

Mary Ellen actually calls this situation a “tightening of controls” from the insurance company to the hospitals. She also says that its those tighter controls that have HELPED them improve their hospital. She says that when she was a nurse, her team wouldn’t think twice about using sterilized wipes (for patients) to wipe down a counter…or wouldn’t give much thought to running a 10th, 11th, 12th test on something…just because. Now they stick to “best practices” which streamline care and keep costs down.

What Mary Ellen wants people to remember is that the greater cost comes in not seeking care. Let me inject a little of my own personal experience here: I started to get bouts of intense pain starting last November and I ignored it until July. Even though the pain was severe I didn’t want to get saddled with hospital expenses or lose time from work. I ended up in the E.R. in May and later in July for exploratory surgery. I am now down an appendix. If I had waited until my appendix had burst…I probably wouldn’t be writing this right now. I too had to experience a push and pull with my insurance company. But in the end, those hassles, that time and what I DID have to pay was worth every penny because I’m healthy today.

“The biggest thing that I can say is, don’t accept ‘no’ for an answer.” -Pat Payne

Pat told me that many claims are rejected because of “code errors.” When a hospital or doctor submits a claim, its done electronically with a code that dictates patient symptoms, diagnoses, treatment, etc. These codes are what insurance companies review and then match to your policy to make sure you are covered.

Pat says that hospitals and doctor’s offices have to churn out a VERY high volume of claims. They are also under time restrictions because the insurance company’s have deadlines. She says that in the crunch, claims get submitted with missing or inappropriate codes and the insurance company kicks out the claim.

Example: you go to the E.R. in excruciating abdominal pain but they can’t figure out what it is. The code for abdominal pain that is submitted to your insurer could mean a WIDE range of things. Unless your records outline how severe your experience was…the insurer may deny your stay because it doesn’t appear the your symptoms were severe enough to warrant a trip to the E.R..

Another example: perhaps the nurse or doctor forgot to include a code. That’s a missing piece of your health puzzle which could cause the claim to be denied.

“If you send in a claim that’s not clear, they’ll throw it right the trash can because that’s gonna take up too much time for them to process that claim,” says Pat.

Pat says that insurance companies often change codes. So your hospital may submit a code that no longer registers with the insurance company’s system (remember: much of this is done electronically). You the consumer have to get in touch with your insurance company to find out the new code and help make a match.

Pat has had her business for 16 years but she’s been in the health insurance agency for 40 (she jokes that she started when she was 4!). She says that, “Insurance companies actually have departments where they have people – all they do is deny claims all day and they get paid bonuses based on the claims they deny. They’re HOPING that you are going to just go ahead and pay the bill yourself.” That’s a pretty heavy charge…so I called the insurance companies to find out if it was true….

I contacted Blue Cross Blue Shield, United, Aetna, Humana & CIGNA. All of them said that there was no such bonus pay system at their company. All of them said that there was nothing out of the ordinary with their denied claims (i.e. an increase). They said they couldn’t provide specific data on their denials without more information…but they didn’t help me figure out what information they needed…OR I was told that the numbers where on the way…but they never showed up.

Apparently, Pat has a close friend who worked for one of these companies who shared the bonus pay tid-bit. Its hard to confirm this without documentation…if you know of where I can look to figure out whose telling the truth…get in touch.

Another piece of advice from Pat: review your hospital bill like your credit card bill, looking at EVERY transaction to make sure it occurred. You may just get an “amount owed” statement but Pat says you should ask for an itemized list. She says that some of her clients have found erroneous charges on their statements that have significantly affected their bills.

 ************************************************************

Here is a more information on how the State is dealing with denials and insurance company complaints….

The North Carolina Department of Insurance has a Healthcare Review Program that receives requests for External Reviews. Consumers go through an External Review after they’ve gone through the denial appeal process with their insurer and are running out of options (read: it’s a last resort). Here’s a video that explains it:

http://www.ncdoi.com/ER/er_home.asp.

Here are the number of requests for E.R.’s that their office has received over the years. Note that not all requests meet the criteria, so the number in parentheses shows how many E.R.’s are actually granted.

2002 – 59 (21)

2003 – 220 (90)

2004 – 201 (77)

2005 —291 (107)

2006 – 255 (113)

2007 – 264 (133)

2008 – 188 (89)

2009 (so far) – 76 (35)

Grand total – 1554

You can see that over the years, there have been an increase in the number of people who are dealing with their insurers and are ending up looking for that “last resort.” But be critical…perhaps the increase is also due in part to more people finding out that E.R.’s are an option out there. An increase in applicants could be due to an increase in awareness.

NC DOI’s Consumer Services Division receives thousands of written complaints every year. They say the vast majority are Life and Health complaints and are a mixture of denials, late payments and insufficient claims (amount paid to consumer). The following numbers are the denied claims data from their office…these are the number of complaints received. Note that in some cases the insurer was determined to be at fault…but not always. Their system cannot separate those two numbers. Again…an increase has occurred, especially between 2007 and 2008.

2004- 1490

2005- 1410

2006- 1420

2007- 1443

2008- 1802

 

If you would like more information about filing an External Review, go here: http://www.ncdoi.com/ER/ConsumerInfo/er_main.asp

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