First of all, let me assure you I haven’t read the 1,000+ pages of the healthcare reform proposal. There’s no way I would have time and, if I did, I probably wouldn’t understand the legalese. Take all the legalese out and I would be willing to bet that it would be a lot shorter. The reason, to me, that it is so long is because it has to cover almost every eventuality that exists. However, this isn’t about the bill. It’s about my own personal perspective.
Healthcare is not “health” care. It’s sick care. Health insurance doesn’t insure health. It insures treatment for sickness. To a point. That’s where it gets sticky.
The people who are protesting any change in the system are either misinformed or haven’t ever been involved in dealing with insurance companies on an almost daily basis. It’s a system that must be changed for the better or it’s only going to get worse.
I’ve spent the last 22 years of my life dealing either directly or indirectly with insurance companies practically every weekday. It isn’t an altogether pleasant way to make a living. If that were all my job encompassed, I might have pulled all my hair out long ago and gone into a different field of endeavor.
Insurances, by and large, are based on the sicker you are, the more they’ll pay but, even then, they won’t pay for every test and/or treatment your doctor orders. I can understand some of it but I see the people in their illness. It’s like one nurse I know…when she’d plead for her patients, the insurance person would tell her, “Pitiful isn’t a diagnosis.” The stress brought about by fighting with the insurance companies can bring on more maladies and shorten human beings’ lives. Stress kills is true.
Bottom line, insurance companies were formed to do one thing—make money. They weren’t formed to take care of little Susie with the illness that only experimental treatment might touch. If they do buckle down and cover it, believe me, you’ll hear about it and maybe in an ad or a commercial on TV if they can’t get the word out any other way. I know one person who needs to have a procedure done but the insurance company won’t cover it because, under her policy, it’s considered “experimental”. That’s even though it’s already worked for many patients.
But now from the medical side to the financial…
In my experience, I’ve seen “superbills” go away. The insurance lobby is the largest in Washington and they call the shots. They have decreed that providers have to submit billings on one of two forms (if there are others, I haven’t been exposed to them). From the time I started working at the hospital, I’ve seen the Uniform Billing form circa 1982 (UB82) go to the UB92 and now to the UB04. The physicians and other professionals have to submit their fees on the form CMS-1500. That’s fine. One problem. Each of the insurance companies have their own ways of paying and their own forms to direct the payments. There’s nothing uniform about them. If we have to be uniform, why isn’t it required of the insurance companies?
Some of the Explanation of Benefits (EOB) are so hard to read, it will take several minutes or maybe longer to just track down which account it should be credited to—or (and this is becoming more and more frequent) which one is being denied payment. Multiply that by 100’s and 1,000’s of accounts. Fortunately, many of ours go directly to Patient Financial Services and some are posted electronically. A lot of the ones with payments that do come to us end up on my desk with a note that the account can’t be located and I spend my time researching it. The others are forwarded on to PFS.
Not all insurances cover the same things and not all policies within those entities are alike. Sure, you can pay thousands of dollars for a plan that will cover anything but most people and employers can’t afford them so we end up with huge deductibles and co-pays or being denied treatment at all. When there’s a balance left, it’s due from the patient and many of them want to argue that they don’t owe it. We direct them to either PFS or their insurance representative.
The associates in Admitting and Registration are expected to keep abreast of which insurance companies cover what and are penalized with a poor grade on the monthly “report card” if something falls through the cracks. They have to know which companies have to be notified if someone comes in for lab work or if they can dispute the pop-up they get on the “scrubber” with the note, “Lab work only. No notification required.” We have a chart for the most common insurances in our area and what they want in the way of notifications/pre-certs. Changes come about daily, and woe to anyone who doesn’t learn them. To add insult to injury, the registration staff is underpaid.
Insurances have to be verified but the resources available aren’t complete or even understandable. We often have to call the companies, anyway, just to get an interpretation. Always, always we get a spiel that says something like, “The benefits quoted are not a guarantee of payment.” It goes on and on, but after awhile, it gets to be like, “Yeah, yeah, yeah.” We’ve heard it all before and we’ll hear it again.
Each facility has a Utilization Review Nurse and/or a Case Manager. Large facilities have a team. Those individuals are responsible for getting the patients’ stays approved by the insurance companies. It’s getting more difficult to get it done and a nurse can stay on the phone for hours on end battling for a patient. This can go on and on. The insurance will, for instance, approve two days for a patient. The nurse has to call back and update at the end of those two days. The patient may not meet criteria as far as the clinical record is concerned but he/she is too sick to go home. Sorry. The insurance won’t pay past discharge time today. The insurance company calls the shots.
On the billing side which we don’t do any more (in some ways that’s good and in some not so good), each of the insurance companies have their own requirements and guidelines. It may have changed since October, 2001, when the billing at the hospital was taken away from us, but Medicare’s timely filing window was a year and three months after the date of service, or, for inpatient, the date of discharge. Medicaid’s was a year. Some of the insurances were 60 days. Some 90. One, I recall, was 45 days. If we got a bill in during that time-frame and there was a problem with it, we made sure that we kept proof of timely filing so we wouldn’t be denied for un-timely filing later. The patients have a hard time understanding that billing insurance isn’t cut and dried and don’t realize it can take, sometimes, years to get a claim paid. That’s an unusual and extreme situation but it can happen.
When I first started working with Medicare and Medicaid back in 1987, Medicaid frowned on weekend admissions. I had to type up a letter of justification and lurk in the hallway ready to pounce on the doctor and get his signature. I did know what I was dealing with, though. Surgeries had to be submitted with medical records and, in some cases, a consent form from the patient. There was one I remember that sat on my desk for almost a full year waiting for everything to come in so I could mail it. I learned to send the documentation certified with a return receipt which added to the cost of the stay.
For all its flaws, I knew what I was dealing with when I dealt with Medicaid. Then along came Ned McWherter and his legacy, TennCare. It was supposed to be a five year pilot plan and, if it hadn’t met expectation by the end of five years, it would be given a decent burial. I always maintained that it would have been better for him to put a naked statue of himself in the middle of Nashville than to saddle us with TennCare. TennCare replaced Medicaid for everything except covering deductibles and co-pays for Medicare recipients qualifying for assistance and it also still covered longterm care.
TennCare. A bad word in my vocabulary. When it first came into being, in our neck of the woods there were five different plans with five different sets of guidelines, billing requirements and reimbursement. They were admistered by five different insurance companies. It was a nightmare. Or five nightmares. One by one, they fell by the wayside and now we are down to two. One of them only covers pediatric patients and high-risk pregnant women in our hospital system. Just the other day, I had to tell a woman she could either go elsewhere to have her lab work done or pay for it herself. She chose to go elsewhere. All of us have had to develop thick skin.
Medicare lulls us into a sense of complacency by doing a post payment review. In other words, they will pay with one hand when billed but then, during a magnified scrutiny of the bill, if it doesn’t meet their requirements, they’ll take the payment back with the other hand. That has brought about medical justification inquiry. It’s #21 on my menu in the registration program we use. Just last week, I found out we can’t trust it completely. There are three things that will come up when we put in the CPT codes along with all the diagnosis codes on the doctors’ orders for outpatient work. If it’s okay, it comes up Medically Justified. If it isn’t, it comes up Not Medically Justified. Then, the third one is No Medical Necessity Requirements. That last one is a gray area. Maybe so and maybe not. How are we to know?? We aren’t coders.
There are good things that have resulted, though. The doctors who send us patients for outpatient work generally comply with putting the diagnosis codes, not just the descriptions, on the orders. The ones who don’t sometimes make the patient wait for, sometimes, hours or days for a new order. That can be embarrassing for us though the patients, by and large, realize we are just doing our jobs. If the patients don’t want to wait, they are given the option of signing an Advance Beneficiary Notice ackowledging that the tests won’t be covered by Medicare and they are making themselves liable for that part of the bill.
The cons outweigh the pros. Something needs to be done. Nothing is going to be perfect. Humans aren’t perfect and what the government comes up with to slow down the avalanche to sheer disaster will be riddled with flaws. What we have is a terrible system. It’s all geared toward the insurance companies and not the citizen. The wild accusations I’ve read in emails I’ve received and on Facebook and Twitter, for the most part, cannot be backed up by facts. The largest percentage of them have been debunked by the organization that assigns “Pants on Fire” to false rumors. (For those not in the know, there is a childhood chant that goes “Liar liar, pants on fire!”) The hysteria that’s out there isn’t helping anything.
My own health insurance costs more than it pays. While my part is less than $500 a year and comes out of my wages, my employer pays far more. I can have lab work with no co-pay, an annual pap smear and an annual mammogram. This is in the name of maintaining my health. What the insurance company pays the hospital is ‘way less than the charges. There’s a “contractual” that’s written off the balance which is usually lots more than the actual payment itself. This is true of most insurances including Medicare and, especially, TennCare. It’s no wonder the hospitals and doctors are hurting.
The premiums keep going up while the benefits go down. As of this fall, I’ll be shifted to another network and, while my premium might not increase, I have yet to find out what the coverage is. I do know that not all the doctors in the area will be taking it. I could pay a higher premium and go to any doctor but, as far as I know, all of mine do take the plan. Not all hospitals do, though. Of course, the ones in the system I work for do. I’m in a better position right now than a lot of my co-workers are. I have Medicare secondary so I can still go wherever I want, in network or out, and pay the same as I would, anyway.
The only guaranteed answer out there is to get healthy and stay out of doctors’ offices and hospitals as much as possible. Most illnesses and diseases are caused by poor diet and exercise habits. Fix those and you’ll go a long way toward fixing what ails you. I’d like to recommend optimal raw vegan food but most people aren’t likely to adopt that lifestyle. Little changes can help. Cut out sodas, diet and otherwise. Eat more fruit, greens and veggies. Eat more raw fruit, greens and veggies. What you do cook, cook as little as possible and as simply as possible. If you have to eat dead animal parts, choose the ones that are raised organically, without antibiotics and steroids. Cut down on dairy and eggs or cut them out. Restrict the cake, ice cream, pie and candy. Eat to live. Don’t live to eat. If you don’t belong to a gym, get out and walk. Do sit ups. Make your heart work for you, not against you. Take control of your life!
Well, folks, there you have it. Just my two cents’ worth. Something’s got to give. And, barring a serious injury or totally unexpected illness, it won’t be me.