CSR: Lo siento, vato. Tienes que llamar otra vez y que te pasen con los que hablan Ingles, loco.
I hang up and call right back, hit zeros, and get the “Sailing” hook again.
CSR: Thanks for calling. How can I help you?
Me: Yes, this is Rick Vassar, my—
CSR: Dude, it’s me, Ted.
Me: Hi, Ted. Listen, I have this claim—
CSR: Sorry, dude. Not covered.
Me: Why is that?
CSR: Uh, no referral—
Me: Well, if you look at the evidence of insurance, on page seven, paragraph four, it states that coverage should be afforded without a referral.
Me: Ted, what’s the problem?
CSR: I told them this was going to happen.
Me: What’s that?
CSR: They told me nobody ever reads the contract...
In the past few years, class actions have been filed against carriers alleging unequal and improper claims handling, offering incentives to doctors not to make referrals, direction of care being dictated by managed care professionals and skyrocketing premiums. In 2003, some of these insurers settled their cases with doctors, agreeing to allow doctors to be doctors, increasing sensitivity to the patients’ needs and speeding up claims payments. Meanwhile, each doctor received enough cash after attorney’s fees to buy a venti latte at Starbucks. Many of these insurers have used this settlement as a marketing tool, reaping free good press well in excess of the amount settled in this "landmark" case. In fact, one of these companies’ stock price has increased over 250% since the announcement of this settlement.
But nothing has really changed. HMOs are still denying claims on a less than equitable basis, and they are denying portions of claims that are not usual and customary (to that particular company), and the patient is the one left holding the financial bag.
As a risk manager, I have a little better handle on what a company can and cannot do, so I can show them how they steered off the path. But millions of people do not know what their rights are, pay what they are told to pay and make health care decisions based on economics.
I have been very fortunate to get most of my claims paid, and I would have to hope that things are getting better. In the meantime, I have one assurance that I can guarantee with the utmost certainty:
I have Ted.