It was an article from Fast Company called “Remedy Wanted to Cut People’s Medical Bills, but the Healthcare System Wouldn’t Let It” that inspired this blog. The article is about a company that made an attempt at lowering patient responsibilities for claims by identifying errors in insurance coding and processing. Remedy did not survive long as a company, and Ben Schiller identifies the main culprit of this company’s untimely demise. He writes, “Remedy failed because it couldn’t get information efficiently enough”. This is a problem faced by many in the industry.

From a medical billing standpoint, getting information is sometimes nearly impossible. We would like to think that there is a uniform set of guidelines that every insurance follows. Yet that is as far from reality as possible. Every insurance has their own guidelines. This of course would be fine, if each insurance had the same rules for every plan. Nope, wrong again. Even the sub-plans under one insurance company have different rules on fee schedules and covered codes.

For example, United Healthcare has commercial, Medicare, and Medicaid policies. Also, since United Healthcare is an umbrella company they have affiliate plans with Oxford and AARP. Each of the affiliate plans also has sub-plans. Meaning, being a par provider with United Healthcare alone means knowing at least 8 different fee schedules and policy guidelines. Guidelines, mind you, that change almost daily. Ever wonder why the same service billed with the same diagnosis has a higher reimbursement from a Medicare plan than an Medicaid one, but the services physicians provide are exactly the same? I wish I had an answer for that question.

This gets so confusing that sometimes (actually in many cases) the representatives of the insurance companies don’t even know the answer. How many times have we all heard the phrase “verification of coverage is not a guarantee of payment”? How many times have we been told a service is covered only to have it apply to some sort of patient responsibility or non-covered charge? Denial reasons totally make sense…said no medical biller EVER! The best ones are “denial as not an approved code,” when you just got paid for the same code from the same insurance on a different claim yesterday. It all comes down to lack of consistency.

Heaven forbid one tries to call an insurance company to get a denial reason. 2 hour hold times. Get a rep on the phone and wait another 10 minutes for them to pull up and research the claim. The rep doesn’t understand the denial because he/she was never trained in claims coding. Best case scenario, they send it back for manual review which takes on average 30 days to process. The really fun ones make you submit written appeals. All to get a measly fraction of what providers should be receiving for services.

Coming back to not getting “information efficiently enough”, I’ll bring up another example. Ever call an insurance company to find out if they cover a particular code with a particular diagnosis? The response rings in my ears loud and clear. “Unfortunately, we are unable to give you that information. You need to submit the claim and have it go through review to determine coverage”. So basically, it’s just a game of trial and error. Today it’s covered, tomorrow it’s not and they backdated the rule to yesterday, so look out for the over-payment letter.

The frustration with insurance companies continues to rise in all medical fields across the board, yet there is still no regulation on any of it. Patients blame providers for overcharging, or expecting them to pay for costs because there is a misconception around what an insurance is supposed to cover, versus what it actually does cover. If we are going to look at issues in the healthcare system, it would probably be advisable to start here. Infinite Medical Billing can help you and your practice navigate the windy paths booby trapped to ensure they don’t have to pay.