Medical Insurance
The Magic You Need to Navigate the American Healthcare Landscape
Employer-sponsored health insurance is not easy street
My employer-sponsored health insurance changes at the end of this year and the transition so far is anything but simple. The perfect irony for someone who works in hospital revenue cycle.
The local University of California has been my healthcare provider for a decade. Having a large teaching hospital as your health care provider extends numerous opportunities. For myself, I get world-class care including cutting-edge technologies, proven procedures, and thoughtful care plans. I also get to give back by voluntarily participating in studies or permitting a medical student to sit in on a clinical visit.
In 2012 my new employer onboarded me with Blue Cross coverage which offered HMO plans managed by the three major hospital systems in San Diego; Sharp, Scripps, and UCSD. I have heard Sharp has an excellent customer service mentality but when it comes to healthcare I want the best life-saving capabilities.
HMO plans pay a fixed fee to medical providers on a per-patient basis which puts the onus of maintaining health on that organization. If your doctor keeps you healthy they get better margins. This works well most of the time but can run into snags where a denial of coverage comes from the same organization providing the service. If this happens to you there are two magic words you need:
- Appeal. The appeals process will resubmit the claim for review. The organization does not like having resources consumed for appeals. Appeal quickly and until you run out of appeals.
- Ombudsman. If an issue is bouncing between the clinic, the internal claims office, and back, ask for the ombudsman. This is customer service at the “heads will roll” level.
Three years ago my employer transitioned the health plan to Cigna and there were no changes to medical services. However, even though I continued to receive care from the same HMO provider, I lost my therapist due to the coverage contract between UCSD and Cigna. Cigna did provide a mental health benefit and I was able to find an excellent therapist in the Cigna network.
This month, my coverage with Cigna ends, and my employer insurance will transition to Blue Cross. The change was touted as a cost-saving to the employees. I will be saving about $8 per month.
The bad news came last month when my therapist informed me she is not in-network for Blue Cross, only Cigna, and she would assist me in finding a new person. I found this unacceptable as I hate starting over, building trust, retelling my history, and then starting the work over again. It’s like failing the first semester in college, a waste of time and money.
Working in “the biz” I figured there must be a way for Blue Cross to bring her into the fold for billing. The magic phrase this time was “continuity of care”. Once that was requested, I was asked to fill out a form. Easy peasy.
Except when it’s not. Working remote means no access to the fax machines sitting in an office I have not been to since the initial Covid lockdown. A call to Blue Cross confirmed the form was only accepted via fax. I found a free online fax service to deliver the document, but since I have seen the horror of how incoming faxes are routed, I called to make sure the fax had arrived and was routed properly. I was told I should call back in a week.
A week later I was told the destination was the wrong department and they could not find the fax.
This time I seemed to have dialed a winning number on the call center Wheel of Fortune. She allowed me to email the form and made sure it was routed correctly. She called the following week as promised with a confirmation.
Still nervous about the authorization, I called to see if my therapist would need to file any enrollment paperwork. It was all in order, but I was told my primary care physician would be changed to a new doctor. One that started his practice when I was in grade school and had middling scores on Health Grades. I could feel the rising fear and hear my voice shaking as I worked through the details with the representative.
I was caught in a Catch-22. I was losing my physician because he was not accepting new patients but he should have a slot for me since they were pulling me out of his practice. As I tried to explain my concerns, spilling my medical history by now, I mentioned a cancer treatment and the conversation seemed to switch gears. Had I stumbled on another magic phrase?
The agent was under the impression I was in active treatment and would need continuity of care. She spoke to a supervisor and after a series of holds and check-ins, she let me know someone activated the check box for adding me as a new patient to the doctor I was already seeing.
A flood of relief, though my nerves were jangled enough that I went and folded laundry and did some ironing (amiright?). As my mind settled down, that evergreen question came back as it has every time I get treatment or deal with a medical bill — How does someone without a background in medicine or medical billing navigate the American medical landscape?
They don’t. Despite the Affordable Care Act, HIPPA, the No Surprises Act, and Medicare, Americans needlessly lose coverage, pay denied claims, miss getting preauthorization, get denied authorization, fail to appeal, lose continuity of care, lose mental health benefits, and generally slip through the cracks. These Americans get sick, go broke, or die needlessly.
If a pandemic teaches us nothing else, it should make clear the need for a national healthcare program. What form that takes is a complex debate for another time. Until then keep a book of magic phrases next to the telephone.
All break images are public domain via publicdomainvectors.org.
