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10-13-2012 08:52 AM
About a month ago, my young friend with the secondhand shop asked me if I could perhaps help her mother handle a problem with her health insurance. Her dad's BlueCross/BlueShield plan was refusing to pay for a brief hospital stay from back in April, and October 10th was her deadline to appeal the refusal desicion.
We met at the shop one afternoon, I glanced through the file and her medical record, which she had already obtained, and allow me to talk to her insurer. We dialed on the cell phone, and she gave the information and authorization for me to ask some questions.
Essentially, what had happened was that the hospital had lowered her bill from roughly $20,000 to $4000. I knew this was just the allowed charge for the services involved. The doctors had all been paid months ago.
What the insurer was saying was that the doctors didn't get permission to admit her as an in-patient. All she needed was a letter from one of the two involved in her admission, to say she had to be admitted for medical reasons. She had been to her local ER two days running, and on this third day, her family decided to take her to a larger medical center. Her headache had not quit, and she was losing her vision, vomitting, and unable to function.
Our second call that day in the shop was to the hospital, to ask for a letter justifying her admisson. I was promised that this would be done, standard procedure. Next day, the same department called her back and told her to "Google the doctor, since he's not still at this hospital anymore."
This lady doesn't even own a computer. She called her daughter, who called me. It took me about five minutes to find him, still with the same practice, in the same city as the hospital, but evidently, they didn't hire that practice to attend as hospitalists anymore.
I got the lady who answered at the doc's office to fax me a release form. I took that, plus a cover letter I drafted to the doctor, explaining the situation, plus a formal appeals letter to cover the appeals form, saying that the doctor had a request for justification in hand, all to my friend. She put in her mom's identifying info and faxed back the release, so the hospitalist could get to her records, now that he was no longer with the hospital.
All of this work was the hospital's responsibility, which we made clear in the letters to the doctor and the insurance company in the letters. You cannot admit yourself to a hospital, and the doctor who decides to do so has to be able to justify his rationale for doing so, so that you can access your health insurance benefits. Patients should not have to do this.
I think this lady was caught in some sort of pee-ing match, betweeen this medical practice and this hospital, which no longer uses that practice. I called my BFF's husband, who is an MD, and he confirmed my suspicions. He also told me that if the hospital coudn't justify why she was admitted, they had to eat the bill.
Anyway, I spent maybe five to six hours, questioning her and the family, reviewing her printout of the Electronic Medical Record, making phone calls, and drafting letters. Her daughter is very bright, and was able to take it up from there. She completed all the letters and got them mailed, certified with return recepit, as I told her to do, so she had proof of mailings.
I had asked her once or twice how things were going, and she called me one day a week or so ago, to ask if it was too soon to call the doctor's office, and see how things were going on that end. She knew when they had gotten the letter, so I told her to call and ask for the same kind lady who had initially helped me, and just say that her mother was very anxious, and she was calling to rest her mind. This was the truth.
I stopped by their house Thursday night on my way home from Jenna's house, to drop off keys for her husband, who is our house painter. He was heading up with one of their teenaged sons, to start Friday afternoon. They use the house to stay over when he's working a weekend up there. The whole family sill stay over tonight, if plans don't change.
She walked me out to the car, and reached inside her van to hand me a vintage pink electric toaster - a real Art Deco design one that still works - as a thank you from her mom. She knows about Jenna's unique pink kitchen.
The letter they needed has been mailed from the doctor's office, and was in her mom's mailbox that day. This is supposed to be all she needs to have her bill paid to the limits of her policy.
We went through a similar runaround when Jenna was sick with viral meningitis at age fifteen. I learned a lot then, and turned a nearly $14,000 bill into one of less than $900 for us. What infuriates me is that, if you don't know how to ask the right questions, and aren't persistent enough, you figure you have to pay out of your own pocket.
While we were sitting and talking at the shop that day, another lady started talking to us. She told me she had to pay for her daughter's appendctomy many years ago, because her surgery wasn't approved in advance - or "preauthorized."
It made me want to cry, because that was exactly what our insurance company said when Jenna was admitted for almost three weeks in 1997...and all it took to shift thar bill back onto BC/BS was a letter from her neurologist, saying that she had to be admitted. That created a "preauthorization after the fact." It's an odd concept, but it's a legal process in the policy, not even an appeal.
One insurnance rep told me about it over the phone, and I made two phone calls. The first was to request the letter. The second was to inform the hospital financial director that the process was being engaged, and the bill should be paid shortly...also, that we would not pay until the letter had been received and the process exhausted. I am guessing he made a call to the doctor right after we hung up, because the letter was sent in record time.
I have learned that you hold onto your money, so that the people you need to perform have some incentive to do so. Our family attorney taught me this tactic...he says that once everyone is paid, they have no reason to help you with letters and such. This is what I told the friend's mom to do...tell the hospital what she was doing, but do NOT pay, until the appeals process was complete.
With the letter she has in hand, her bill ought not to exceed a few hundred dollars. No free, but not $4000 either. There is no excuse for a patient being put through this ordeal, for what the doctors ought to have done automatically.
This is what infuriates me...that families all over are struggling to pay bills they do not owe, because they don't understand the legal ins and outs of their medical insurance. I feel good that we are getting the necessary results this time...has anyone else had a similar experience?
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