Health Insurance: Driving the Craziness

[TexasTowelie]

By Dr. Brian Carr
President, Behavioral Health Associates, Lubbock, Texas, 1991-Present
Chairman, City of Lubbock Board of Health, 2013
Submitted on July 30, 2013 - 8:07am

To understand how broken the current health insurance model is one need only receive an “Explanation of Benefits”. Everyday my office files insurance claims and receives correspondence back from insurance carriers.

The “Prime Directive” of insurance is to capture as much as possible in premium dollars and pay out as little as possible in claims. This leads to a shell game of back-and-forth messaging where the issue of actual care is of little importance. What matters is proper authorization, endless medical review by individuals of questionable educational background, and “got you” moments when your claim is denied based on rules enforced by manner directed by chaos.

Yesterday I received two sets of correspondence that demonstrates the problem. To protect the first insurance carrier let me just say that their name sounds nothing like “NoCare”. NoCare is a carrier that was once locally based but now has grown to the point where they have relocated to Austin. I am very careful in obtaining pre-authorization from NoCare and submitting claims that are error free however my collection rate (what I actual receive as opposed to what I charge) is the lowest among all carriers, hovering around 47%. NoCare will deny claims stating I did not obtain pre-authorization (even though I submitted the correct authorization number), they will simply not pay a claim (forcing me to closely monitor to catch later payments while failing to pay earlier ones), or they will mismanage the entire process to the point where the claim is denied because, as noted in my letter from them today “the time limit for filing has expired” (Because they delayed it in the back and forth review process). One way that NoCare delays claims is that they are one of the very few carriers that requires you surface mail your claims. All of my other claims are submitted electronically (read quickly) while NoCare requires I use a paper envelope and stamp to submit claims. A nice way to slow everything down.

A second company we will call Inferior Health Plan is a managed care Medicaid program for Texas that is located in a far north state (apparently Texas cannot manage insurance within our borders). Today I received the following denial:

“The claim submitted was black and white. Only claim forms that are printed in Flint OCR Red, J6983 (or exact match) ink are accepted as of 4/1/13”.

So, in order to comply with this ONE carrier I must purchase pre-printed forms with the absolutely correct exact match ink, the purchase a printer that can print on the form, then surface mail off the claim.

Inferior Health Plan is the only carrier I submit to that demands the exact match red form.

Does any of this process related to the care that is provided?

The purpose is merely to slow, delay, and deny claims. It is no wonder that providers are angry. While issues of payment and reimbursement are one part of the discussion the other is the insanity of the specific requirements to even submit claims.

Medicare may have its issues but mind-boggling idiotic rules for claim submissions are not the issue. It is within the carriers such as Nocare and Inferior Health Plans that one witnesses the strategy that is designed to deny care and maintain profits.

Bring on the Affordable Care Act and let the country tweet the standards. To continue to work within the existing modal of care will ensure the destruction of our country. Just get your insurance EOB today and watch what happens.

TAGS:

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http://lubbockonline.com/interact/blog-post/dr-brian-carr/2013-07-30/health-insurance-driving-craziness

[area51]

1. Exactly why the GingrichCare that we got will ultimately fail.

It's GingrichCare because it puts private, for-profit, serial-killer insurance agencies in the driver's seat, and is using the IRS as an enforcement mechanism.

Fsck it, we need single-payer. People are dying due to the lack of regulation of these agencies.

[UglyGreed]

2. Single Payer

Health care is a right above all else!