Insurance "errors"

It seems like every time I log on to our health insurance website to review our recent claims, there's some kind of problem. And considering that we are generally healthy people, we see the doctor a lot. Callum's well-visits are frequent (though thankfully now that we're past 18 months he's down to the regular once a year schedule, starting at age two). He usually has a couple sick visits per year, too. Torsten and I get annual physicals. Torsten had his gallbladder out and all the accompanying doctor visits and follow-ups. He is also mole-prone and goes to the dermatologist annually. I have my annual gyno exam and my regular endocrinologist visits and my occasional lap-band fills and bariatric surgeon check-ins. And we all get flu shots each year, which we do through our PCPs so our insurance will be billed directly.

So yeah. Relatively healthy, no major illnesses, but a fair amount of visits to the doctor in our lives. Thank goodness for good health insurance. But when I say "good" I mean that they pay for things... when we force them to.

It's not as bad as some. We've never had our insurance company outright deny coverage (other than for my lap-band, which was truly excluded, and of course the insurance plan we're on now that I've changed jobs DOES cover it but whatever, it's water under the bridge and anyway, I wouldn't have changed the timing of that surgery because it impacted pregnancy timing, so). But, we do constantly seem to get bills for medical things that are supposed to be covered. And whenever we look into it, it turns out it was the insurance company's fault. And they fix it! They do! And they're nice and helpful on the phone! But, if I didn't call? We'd be paying quite a bit of unnecessary money.

For example: when Torsten went to the ER with his gallbladder attack, we made sure to pick an in-network ER, for which we have a copay but no deductible or coinsurance. In other words, we paid a flat one-time fee ($125) and nothing else. But then, weeks later, we got a bill from a radiology imaging company, saying that we owed them $42. I checked the insurance explanation of benefits and saw that they were saying the ultrasound had been performed out of network, even though it was done at an in-network hospital. A bit of research showed that this is technically possible (which is also disgusting, but that's a separate discussion), but when I called the radiology company, they told me that they ARE in-network for our insurance. So then I called the insurance company and they looked into it and oh! Surprise! Our mistake! We entered the wrong code! They are in-network! No worries, we'll just pay that $42 for you. Thanks!

Another example: Torsten just went to the dermatologist for a routine visit and had a mole removed and biopsied. The dermatologist was in-network and all we had to pay was a co-pay. Until, in addition to the bill for the dermatologist he actually saw, we also got a bill for $106 for some other random dermatologist in the practice, whom the insurance said was out-of-network because Torsten didn't have a referral to see him (which he didn't, that was true--because he didn't see that doctor! He DID have a referral for the doctor he ACTUALLY saw). I called up to ask why we were being billed for a visit to a doctor neither of us had ever heard of, and they looked into it, and oh whoops! That was pathology, not an office visit! Our mistake! We entered the wrong code! They are in-network! No worries, we'll just pay that $106 for you. Thanks!

Example the third: Callum has had all the usual well-visits. We switched insurance between his 6-month and 9-month visits, because I changed jobs. There is no copay for those visits so we pay nothing out of pocket. Until we got the bill for his 18-month visit, for $357. The insurance EOB said that we had "exceeded the maximum coverage for this benefit." When I called to inquire, I was told that he had gone to more than the covered number of well-visits for his age. I asked how that could be, since he only went to the standard set. They told me they covered seven visits the first year (that would cover 3 days, 2 weeks, and 2, 4, 6, 9, and 12 months) and two visits the second year (that would cover 15 and 18 months). That's exactly what Callum had. When I pointed this out, the woman was silent for a long time as she did god knows what in their impenetrable system, and oh whoops! We assigned his 12-month visit to the second year instead of the first! Our mistake! No worries, we'll just pay that $357 for you. Thanks!

And these are only the first three examples that come to mind! They do this ALL THE TIME. These three instances all happened within the past few months. There are also a million other examples, though sometimes smaller like when they say we owe a few dollars for bloodwork when we really don't, or that a test isn't covered when it really is.

And you know what? I think they do it on purpose. Not everyone bothers to call up when they get a bill, especially if it's just a few dollars. Most people probably would have called for that $357 pediatrician bill. Probably also for the $106 dermatologist bill. Maybe not quite as many for the $42 ultrasound bill. And I'm guessing almost none for those $5-$10 charges for labwork and whatnot. It's just not worth your time to haggle with an insurance company over a few dollars, right? When they're so bureaucratic and impenetrable and immensely frustrating?

But they're COUNTING on that, aren't they? If an insurance company has a million members and they make "errors" that charge those members an average of $5 extra per year, that's a cool $5 million they've made for doing absolutely nothing. And just think how many members probably pay even more than that because of a coding error, or an interpretation error, or a date confusion, or some other insane technicality. Just think how many people probably pay the bills when they receive them and assume it's their own ignorance about the inner workings of the insurance company that's the problem, rather than an actual insurance error.

In fact, thinking back to when Torsten had his hematoma surgery a few years ago? I was much less informed about insurance companies than I am now, and we weren't married yet so we had separate insurance and I was unfamiliar with the details of his coverage. But his insurance was supposedly great, and yet we kept getting these BILLS after it all ended. A few hundred to the anesthesiologist. A few hundred more to the hospital. A few hundred more to the surgeon. And on and on. Overall we paid over a thousand dollars out of pocket for that surgery, in addition to the original copay, despite the supposedly excellent insurance. And we paid those bills without questioning whether they were accurate. We didn't even look into it. I don't think we explored the EOBs to see what the reasons were for less than complete coverage. We certainly didn't call up the insurance company or the medical providers to ask. We just... paid.

And maybe that was right. Maybe he really did just have fairly crappy insurance that was oversold as excellent and that didn't provide full coverage. But maybe not. We should have called to be sure. And it never crossed our minds. And I'm sure it never crosses the minds of lots of other people who receive unexpected medical bills despite their expensive health insurance.

So, lesson learned: whenever we get a bill we don't think we should have gotten, we always, always call. Our insurance company has been shockingly helpful and efficient over the phone. I have yet to ever have a charge I've questioned upheld. They have ALWAYS been reversed. And so I will keep calling. Because they should not get away with this. Even if they're true unintentional errors, they need a system that prevents people from being erroneously billed. It should not be our job to sort through impenetrable language and complex insurance structures to figure out if we really owe what they're telling us we owe.

But frankly, I just don't believe that these errors are unintentional. I think it's a nasty racket. Even if it's only $3 in question, just on principle, I will ALWAYS call.