Wednesday, October 17, 2012

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.


  1. This makes me very, very happy with my insurance company as we've never paid a dime more than the copay for...anything. Never gotten extra bills, never had anything denied. I think it makes a big difference, though, that we live in the city the insurance is based out of so it would be difficult to find a doctor who *wasn't* in network. Everyone is.

  2. Our old insurance was amazing. I was hospitalized for 3 days before I had an emergency c-section and stayed in the hospital for 3 more days. Gavin was in the NICU for 5 weeks. For all of that PLUS all of my OBGYN visits during pregnancy, we paid only one co-pay for a whopping total of $20. Hundreds of thousands of dollars in hospital bills and we paid $20. Amazing.

    Our insurance has changed since then and Sweets' hospital stay this summer will cost us in the range of $2,000. To be honest, I don't even know where to begin in terms of what's covered, what isn't, how much is our own responsibility, etc. It's so stupidly complicated that a rather smart person (let alone average) just can't be bothered to take the time to figure it all out. Just yesterday, I paid the largest of the bills, no questions asked. Guilty as charged.

    Are you available for hire? =)

  3. I don't work on the insurance side of things, but I do work for a large health company. When I write something that's clear and to the point in an effort to make things easier for people to understand, our clinical and legal departments eff it up so bad it ends up being nearly indecipherable. Drives me insane.

  4. I feel like I am CONSTANTLY dealing with billing errors lately. I've gotten a $13 service fee taken out of my Wells Fargo account for the past 3 months, and each time I call they reverse the charge and assure me it won't happen again...and yet it does, and then I have to call again...

    And I'm on an unemployment deferment for student loans and they keep sending me bills, I keep calling and they "fix it" and then I get more bills...

    It is really effing frustrating. Can't wait to see what our new insurance and having a baby brings!

  5. Grrr. And there's not even much point in complaining, because as you said, this is basically intentional.

  6. I ABSOLUTELY BELIEVE they do this all the time, on purpose. EVERY SINGLE TIME I've called with a question, it's gone just like with you - oh! whoops! you're totally right! sorry about that! - and poof it's gone. But I DON'T call every single time, because I tend to be insanely busy at work during the only times the call centers are open, and it is often easier to pay the bill rather than fight both that bill AND the late charges down the line. Which makes me furious at them AND at me for allowing them to take advantage of me.

    To sum up: I agree, they are doing this on purpose, and assuming most people are not checking on it and that is SO DIRTY AND DESPICABLE.

  7. Like Jessica (above), I am now very happy with our insurance! We've also never had to fight anyone for any charges, nor have I seen a bill for anything since we switched 8 years ago from the horrors of Blue Cross to a much better CIGNA plan.

  8. I've been so lucky to have great health insurance through my employer. I've had problems once, and it was office billing errors, not insurance's fault. And I agree- ALWAYS CALL.

  9. Wow, that is really eye opening. I get very confused about EOBs and bills so I just pay them. I am not going to do that anymore! I've probably spent so much extra money that was not actually owed. That makes me mad!! Thanks for opening my eyes to this.

  10. I received an EOB after my daughter was born telling me I would have to pay $13,000 because the hospital where I delivered was out of network. I called them immediately, and, same as you, it was all "oops, our bad! Wrong code! You're totally covered!" What, did they think I would just pay 13 grand without questioning it?

  11. Wouldn't those charges go to the actual dr's office, not your insurance, since you're having to pay for what the insurance company wouldn't cover? Unless they're getting some sort of kick back from this I don't see how it's a racket on the insurance company's part. Don't get me wrong, it is definitely annoying to have to fix someone's mistake for them, and I think insurance companies can be intimidating and some are scheme-y...and it's super annoying that you've had to deal with this over and over and over! blah.

  12. Emily: The doctor's office gets paid a set amount that they have pre-negotiated with the insurance company. The question is how much of that amount will be paid by the insurance company and how much will be paid by us. So when our insurance company denies something as out of network, yes, it goes back to the doctor's office and the doctor's office sends us a bill, but if we just paid that bill instead of calling the insurance company to sort out the error, that would mean that we were paying money that was actually owed by the insurance company, thus saving the insurance company that money. Does that answer your question?

  13. Since there are 6 of us, we are constantly getting little bills for this or that. I think I need to read up on my insurance a little more...

  14. Aha yes- thank you. My pregnant brain couldn't quite wrap itself around that entire concept. Duh. :)

  15. It is absolutely done on purpose, I'm sure. Insurance companies are evil, and they employ several methods to pay their profits at the policy holder's expense.

  16. Universal health care FTW! ;)

    (And my sister says, "Hands off my health care!" Oh yeah, get your hands ON my health care because it's pretty screwed up.)

    But seriously - this is beyond frustrating. BEYOND.