One of the most visible changes in the new health insurance reality are the medical bill surprises people are receiving that they never received before, for services covered previously as a matter of course. You know – whereas their insurance automatically approved a CT scan for purpose X in the past, now patients need pre-approval. Without that pre-approval, payment for that CT scan comes out of their own pockets – totally unexpected and usually very expensive.
Most of us learn the hard way that we need to get permission for many of the services that used to be automatically approved. I know I did. About two years ago I received the full billing ($350) for my annual trip to the dermatologist. I had been referred by my primary, the check-up was a covered benefit, but because I hadn’t gotten it approved ahead of time, I received the bill, and was told I was responsible for the full ride.
I was stunned! And angry, too…. When I called my insurer, the customer service rep told me that was their new policy, and I was out of luck; there was nothing she could do to help me. When I asked when the rule had changed, she told me she wasn’t really sure. When I asked why I had never been notified, she said she didn’t know… Bottom line, I got NO information from her. I finally asked to speak to a supervisor who was even less helpful – until I told her I would be in touch with the state insurance department. Only then did she say she might be able to help me sort out the billing. Eventually they did cover the cost of my appointment – because they couldn’t prove to me that I had ever been notified of the change in policy.
I’m not going to lament here the fact that it seems like nothing can be done by customer service these days without threatening them first. Instead let’s look at some lessons for advocates; that is, that when we know we need something, or when we are stonewalled, the only real answer is “that’s not good enough.”
I raise it today because it almost happened again last month, as follows:
During a check up with my primary, she suggested I get a dexa scan. A dexa is a bone density scan, often used to screen for osteoporosis. My last dexa was only a few years ago, but my primary recommended I have one every two to three years because of a drug I take that can weaken my bones.
As I checked-out after my appointment, I was told I could go right on down the hall for the scan. I told her I couldn’t do that because I needed to check with my insurance first. “Oh no – don’t worry about it – dexas are always approved,” she told me.
“I don’t do anything without permission in writing,” I told her. “Once burned, twice shy, and all that.”
“Well, we’ve never had anyone turned down,” she replied. I thanked her, and went home.
Once home, I found a voice mail informing me that I had been rescheduled for the dexa for the next day. Seriously? So I called them, and rescheduled for a week later, then called my doctor’s referral office and asked them to forward a copy of their approval for my dexa scan. “Oh, you don’t need to wait for that,” I was told. “Dexas are always approved.”
Sorry – that wasn’t good enough for me, I told her.
So I called my insurer, told the insurance rep what I was trying to get a copy of the pre-approval for the dexa, and she told me they would first have to get the script written from my primary. I told her I couldn’t seem to get anywhere with my primary’s referral people because they considered the permission for a dexa to be a matter of course.
“Oh, it is,” she told me. “They are always approved.”
“That’s not good enough,” I told her. “I’ve been burned before by something that was always a matter of course. I want the paperwork in hand before I get that scan. Will you tell me what I’m covered for, exactly?”
So she pulled up my records, and my policy. “Here – you can have a dexa once every five years for osteoporosis screening purposes. No problem.”
“That IS a problem,” I told her. I just had one three years ago but because I take a PPI I need to be screened more frequently.”
“Oh – then yes you’ll have to get pre-approval for that.” I didn’t know whether to scream — or to sing because I had been right.
“So what’s the difference?” I asked her. “How could you be so sure – and yet so wrong?”
The answer was because the pre-approval would have to mention why an earlier screening was necessary – the drug I was taking – which would require a different code.
All I could think of was that it was a good thing I hadn’t trusted anyone who told me I didn’t need pre-approval. I called my primary’s referral people back, told them what I had learned from the insurer, gave them the explanation about the code, and a few days later, got the letter in the mail with the pre-approval. I went for the scan the next day. (And, thankfully, my bones are doing just fine, thank you!)
If I hadn’t been so diligent, so pushy, and insistent that what they were doing wasn’t good enough, I’d be writing a big check about now.
Many of you reading this post today are medical billing and claims people. This is not only nothing new to you, but many of you make plenty of money sorting out these problems on the other end – after the service is performed even though no pre-approval had been sought. I hear you, en-chorus, singing “What else is new?”
But if you are an advocate who doesn’t typically deal with insurance pre-approvals, there is really far MORE in this post for you. “Sorry, that’s not good enough” can help improve your practice in a number of ways:
1. You can use it for marketing purposes. Explain to potential clients that you’ll be tenacious in pursuit of what they need and that you’re not afraid to drop a “sorry that’s not good enough” on anyone who needs to hear it.
2. You can use it for public speaking – another marketing strategy – to teach potential clients during a talk or workshop that “Sorry, that’s not good enough” is a way of laying down the gauntlet, insisting that the party who isn’t upholding their part of the bargain do so. (And oh, by the way, that’s what you do in your work as their advocate.)
3. Finally, just that statement, “Sorry, that’s not good enough!” should be an almost daily mantra for you in the work you do for your clients. The entire nature of our work is to be sure that our clients get what they need. Too often providers offer a partial solution, or something interim, or even just ignore requests. “Sorry, that’s not good enough” is both an attitude and a statement that will serve you well, spoken and unspoken, as you stick up for your clients and move their needs forward.
Yes – the sands of health system interface continue to shift beneath our feet. The more difficult it becomes for patients to get what they need from the system, whether that’s getting pre-approvals, payment, or medical services themselves, the more patients need us.
What they really need from us is the refusal to “settle” for less than they deserve. “Sorry, that’s not good enough” is what will get them what they need.
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Share your experience or join the conversation!
Thanks for for a great teaching and learning experience. Your story also highlights the lack of accountability so prevalent in our healthcare system.
Your doctor’s office said dexas are “always approved.” Does that mean if they are wrong you won’t have to pay? No. Your doctor’s office is not held accountable for the consequences of their mistake.
Your insurer told you, ?They are always approved. Always? Wrong, totally wrong. But if you acted on this information, your insurer would not have paid your claim. You would have been held accountable for your insurer’s mistake, not your insurer.
This lack of accountability is not restricted to insurance. If your surgeon accidentally leaves a sponge inside you, will he bear the expense of fixing the mistake? No, you will pay the copays and coinsurance and and you will bear the burden of related expenses not covered by insurance.
Instead of saying ‘sorry that’s not good enough? I usually say, ?Could you please provide me with documentation for that so I will have something to put in my files?”
My boss taught me this lesson years ago when I was a book buyer. He wanted to know whether an order I had placed with Simon & Schuster had been shipped.
?Yes,? I said. ?I called the warehouse and they said according to the computer the books had shipped.”
?Did you get a pro number> he asked.
?What’s a pro number?”
?A pro number is essentially a tracking number. If the books have really been shipped, they will have a pro number.”
I called my customer service rep at the warehouse, but this time I did not ask him if the books had shipped. Nor did I challenge the information in Simon & Schuster’s computer. Instead, I asked him for the pro number.
?Hold on,? he said. ?I’ll look it up.”
You know how this ends. The warehouse rep could not find a pro number. He went down to the warehouse floor and learned that, despite what his computer screen indicated, the books had not actually shipped.
Fab, Fab, fab! What an awesome article. Can’t wait to share everywhere. Thanks for sharing your insight and experience.