Hard agree, and not just because I'm a spreadsheet nerd. Why are we all here? Isn't it in the service…
Morning Headlines 12/30/14
Accenture wins $563M contract to continue with HealthCare.gov
Accenture signs a $563 million five-year contract extension with HHS to manage and continue developing healthcare.gov.
ICD-10 Testing Results and DMEPOS Competitive Bidding Registration Reminder
CMS reports that during its November ICD-10 open testing period more than 500 providers, suppliers, billing companies, and clearinghouses submitted test claims, resulting in a 76 percent claim acceptance rate. The test checked that claims had a valid diagnosis code, ICD-10 companion qualifier code, national provider identifier, and date of service, and returned an automated acceptance notification when all criteria were met.
Startup Health Insights Annual Report 2014: The Year Digital Health Broke Out
Startup Health reports that $6.5 billion in startup funding flowed into the digital health sector during 2014, a 125 percent increase over 2013.
PCORI will award $87 million to establish 13 clinical data research networks and $26 million to establish 22 patient-powered research networks as part of the second phase of its PCORnet project.
Do you want to know one reason why healthcare in the US sucks? Read below…
My wife had her annual physical a few weeks ago. After the lab results were back the Dr. requested she come back to have another mammogram to make sure there wasn’t a problem. As you can imagine this was a stressful situation that was made 10 times worse by unnecessary confusion, bureaucracy and incompetence from employees from a MAJOR HEALTH SYSTEM and a MAJOR INSURANCE COMPANY.
My wife was told the day before the appointment that she would need to pay $450 since it was a diagnostic appointment and not an annual physical. After hearing this, I called the insurance company to verify. I was told that a pre-authorization had not been done, but the procedure would be covered if it was a medical necessity. If it wasn’t a medical necessity, then why would the doctor order the damn test? (Am I just supposed to say sorry Doc, Insurance Company says you’re a fraud? Patients should be able to trust that doctors will order medically necessary tests and trust that insurance companies will pay for them). So I called the health system again and was told that pre-authorization wasn’t needed and they said I would need to pay the $450. After explaining to the gentleman from the health system that the insurance company said the pre-authorization was needed, the health system rep told me I need to talk with a financial consular to get all of the correct information so that I could then contact the insurance company to get the pre authorization.
I called the financial counselor and naturally had to leave a voicemail…never heard back from them. So I called the pre-authorization group again. They said they don’t do pre-authorization (they answer the phone as pre-authorization so that must mean something else). I argued enough so that a supervisor would get involved.
And the hits just keep coming…
The supervisor said that it was the doctor’s office responsibility to get the pre-authorization, but they didn’t do it. I asked then why didn’t the pre-authorization team that I was dealing with take care of this and follow up with the doc? Apparently, that’s not part of their responsibility. Seems like they hoped I was stupid enough (that’s another argument) to follow up and ask questions and would just hand over my credit card. After being on hold for an episode of Sons of Anarchy, I was told that the Insurance Company didn’t need pre-authorization for the procedure. Will that be cash or credit card?
So another call to the insurance company to see why these medically necessary procedures wouldn’t be covered? They said pre-authorization was needed. Wait a minute you say…didn’t the health system just call the insurance company and conclude that no pre-authorization was needed? So after another long wait on hold the insurance company confirmed that the Mammogram was covered 100% in network and I should have no balance due and no pre-authorization was needed. I called back the health system and they said that it wasn’t covered by insurance because it was a diagnostic procedure…I can’t wait to start this fight all over again in 3 weeks when I get “statement of benefits” and the bill.
I’m fortunate that I have a flexible work schedule that allowed me to spend 4 hours of my morning to deal with this insanity. My wife is a teacher, she just can’t leave the classroom to deal with this crap. What bothers me more is that the health system was pressuring my wife to fork over a credit card to pay…and offered a 20% discount on top if we would pay at the time of service. This isn’t the first time this has happened and the other times the health system was just as wrong. I may be over stepping the bounds here, but this borders on fraud to me…this is a systemic problem (or intentional process) and makes health systems look as bad as the “big bad insurance companies”. Starting to wonder why I chose this industry…
Fast forward two weeks…
I just received a bill for $403 for a mammogram that was covered 100%. So I guess I get to do this all over again…