BEND, Ore. (CNN/Money) -
My twin daughters' recently celebrated their first birthday. And like most parents, my husband and I were proud to watch them stuff fistfuls of cake into their mouths.
For us, however, the day was especially victorious, not just because the babies -- who were born more than two months premature -- needed a whole lot of modern medicine to get to their first birthday. But also because after nearly a year of wrangling with our insurance company, we finally managed to get all of that modern medicine paid for.
Our medical meter started ticking away on July 10, 2002 when my daughters, Fiona and Isabel, were born weighing just 3 pounds each.
|Isabel and Fiona one year and $200,000 later.
When our bundles of joy came home from the hospital, two months later, so too came a bundle of bills, totaling $200,000. In the end, I paid only a fraction of the tab because, unlike the 15 percent of Americans who are uninsured, I'm on the payroll of a large company with generous health benefits.
But it wasn't without a fight.
I spent much of my maternity leave sifting through bills and acting as the go-between for my docs' offices and my insurer, United Healthcare. Each blamed the other for unpaid claims. With some charges, it was just a matter of asking -- usually more than once -- that they be "resubmitted."
Other unpaid claims, however, weren't so easy to handle.
Most memorable was a $2,139 charge from the pediatrician that insurance paid for Isabel but not for Fiona, who had identical service. As it turns out, the pediatrician's office used the wrong dates on the claim. It was a simple error that became a yearlong headache.
Each month I got a new statement from the pediatrician, and each month I called my insurer only to get a different reason for why that charge was not paid, including: it was already paid, the procedure wasn't covered, it was part of my deductible and, best of all, job-related injuries weren't covered (huh?).
The only breakthrough came in May when my husband and I resorted to calling on a speaker phone. When we informed the representative that we, too, were recording the conversation for "quality assurance," we finally started to make progress. Just in time for the babies' first birthday.
Patients vs. profits
According to United Healthcare spokesperson Mike Strand, less than 1 percent of all claims the company receives are mishandled due to its own errors.
Still, my experience seems to be a common one.
In a world where companies strive for efficiency and go to great lengths to improve the customer experience, both patients and physicians scratch their heads at the complexity of many managed health care plans.
"Those of us who do this for a living can't even decipher our own policies," said Kathleen Stoll, director of health policy for Families USA, a non-partisan healthcare advocacy group. "It's very hard to navigate what's covered and what the limits are."
In fact, the business practices of major HMOs are the subject of a national class action lawsuit on behalf of more than 700,000 physicians. The multibillion-dollar suit, which came together in August 2000, alleges that insurers systematically reduce, delay and deny payments.
"We have had many occasions where the physicians feel the insurance companies are just trying to wear them down. They'll lose a claim, ask for more information or change the fee schedule," said Roberta Sorensen, executive director of the Medical Society of Northern Virginia, one of the plaintiffs in the case. "I think the average patient, when faced with these long drawn-out disputes, just gives up," she added.
The trial is set to take place in June 2004. The HMOs, however, have appealed the physician's class-action certification, and are waiting for a decision from the 11th U.S. Circuit Court of Appeals in Atlanta.
Kent Jarrell, a spokesperson for the eight non-settling HMOs said that the companies had already been making improvements to how claims are processed. He also denied the notion that insurers intentionally wear down physicians. Doing so, he said, would not be in the best interest of the HMOs. "If efficient medical care is delivered, that's good for us," he said. "We don't want to gum up the system."
Unraveling the red tape
Intentional or not, there's no question the managed care maze is a complicated one to navigate. But there are some ways to put yourself in a better position.
Don't leave it to the docs "Never assume your doctors office understands anything about your health plan," said Sorensen, of the Medical Society of Northern Virginia. "Physicians' offices deal with hundreds of plans and hybrids of plans."
What's more, you shouldn't assume that the customer representative at your insurance company have memorized every detail of your plan. Each plan is different depending on the benefits set up by your employer, noted Strand of United Healthcare.
Review the ins and outs of your plan on an annual basis, rather than trying to make sense of it all when you or a family member is sick or injured.
Check the math When the bills start rolling in, carefully scrutinize the providers' invoices as well as the explanations of benefits (EOB) insurers send out.
In particular, pay attention to the "amount allowed" and the percentage of that amount paid. If you think it falls short, call your insurer on it -- though you shouldn't assume what you're told is the right answer.
As a matter of habit, keep a customer service journal of every phone call you make, including the date, time, name of the representative (or their customer service ID) and even the amount of time you were on the phone, including hold times.
It might seem like overkill, but you'll find that when you can read back who said what and when, you have far more leverage.
Know your right to appeal In 44 states, customers in individual plans or group plans purchased by their employer have the right to an independent review of their insurance disputes.
First you must formally appeal to your insurer, typically two times. (Be sure to specifically request information on an internal review process from your insurer; calling customer service and complaining does not count.)
If your insurer does not rule in your favor, you can request an independent review, which is overseen by state insurance departments. In most states, the review is free, though 10 states charge $25 and four states charge $50.
Half of the cases that go to an external review side with the patient, according to Georgetown'sHealth Policy Institute.
There is, however, one big caveat: Employees in so-called self-funded plans, which cover close to half of all workers, do not have access to the states' appeals process. "Often their only recourse is to pursue actions in court," said Kevin Lucia, a researcher with the institute.
Find help, for free Despite your best efforts, you may have a tough time weeding through your medical bills and insurance details on your own. Not surprisingly, an industry of for-profit medical billing experts has cropped up to help people make sense of it all.
But before you pay someone to settle your bills for you, see if you can get free help from an advocacy group.
Such organizations as the American Cancer Society provide support for patients with concerns over bills or denied coverage. Families USA, meanwhile, refers people to local ombudsmen who help people for no cost.
Another group, the Patient Advocate Foundation, has a staff of case managers who, for free, will assist any patient with a chronic, debilitating or life-threatening disease.
"Last year we were contacted for help and or information by 2.4 million Americans," said Beth Darnley, executive vice president of patient and public relations for the group.