Pandemonium

On Being a Responsible Consumer

Again today I had to contact our dentist to inquire as to why the service they billed to our insurance company was not the service we received. It's not always the dentist, sometimes it's the ob/gyn, the dermatologist or the eye doctor. The scenario usually plays out like this:

1. Practitioner tells Patient he needs Service X
2. Patient trusts the Practitioner to know what's best for him and agrees to Service X
3. Patient doesn't know if Service X is covered by his insurance company, but he trusts the Practitioner and is sure that the Practitioner would not recommend something not covered without advising him of such.
4. Patient receives Service X at the frequency prescribed by the Practitioner and is happy. Until the first EOB arrives.
5. If the Patient is up on his medical documents, he knows that the EOB is an Explanation of Benefits and that it tells him how much of Service X the insurance company will pay for.
6. If the Patient is not well versed in this process, he may receive the EOB and not really understand what it means or what he needs to do at this point.
7. Soon the patient will receive a bill from the Practitioner for the amount of his bill not covered by his insurance. If he doesn't know any better, he will then write a check to the Practitioner

It doesn't always work out like this. Sometimes the Patient knows that not all services in the world are covered by his insurance and he questions the Practitioner about this. For example:

1. Patient is told by Dentist he needs to have teeth cleaned every 3 months instead of the traditional every 6 months.
2. Patient knows his insurance only covers cleanings twice a year.
3. Patient asks the Dentist what the fee is for cleaning, knowing he will have to pay for 2 of the 4 cleanings out of pocket.
4. If the Dentist's fees are acceptable to the Patient, the patient agrees to the recommended course of action.
5. If the Dentist's fees are not acceptable to the Patient, the patient informs the Dentist that he will only be returning twice a year for cleanings and that he understands that this is less than optimal.

In that scenario, the Patient was actively involved in his treatment planning, understood which services and frequencies were covered by his insurance, weighed the costs and benefits of exceeding that coverage and made an informed decision. Not everyone in the world has the knowledge, time or patience to do that and I think many providers take advantage. Whether it be maliciously (intentionally upcoding to try to obtain a greater reimbursement from insurance carriers and/or patients) or through sloppy business practices (incorrect procedure code used on claim), many patients and their insurance companies are paying far more than they should for services.

In the time I've worked in the health care field, I have seen the following billing issues:

1. Services billed to the wrong client. Insurance paid anyway.
2. Wrong procedure billed
3. Wrong date of service billed
4. Wrong number of services billed
5. Female-specific service billed to male client's insurance
6. Labwork sent to the wrong lab (some insurance companies use a preferred lab for their network)

The best advice I could give is to become an informed consumer of medical/dental/optical services. Unless you are a member of the type of HMO that covers everything as long as you follow their rules, you most likely have a set of services that are not covered by your plan. Read all of your plan materials and make note of what types of services are not covered or require prior authorization. Call the plan and ask questions if you do not understand. When at the doctor's office, inquire about which lab will be used to process your blood work/biopsies. When faced with multiple options for treatment, ask about the pros and cons of all and find out which ones your plan covers. You may still opt to have treatment that is not covered, but *you* are making that decision, not the provider.

All providers are not evil and out to wring every last dollar out of you. However, they are also not highly concerned with your situation. It is up to the patient to arm himself/herself with the knowledge and the assertiveness to ask questions and assist in the treatment planning process.

Be well,
JG

Bad Grammar Graph

I did not create this graph, but I *so* wish I had.

more graph humor and song chart memes

We Put The Fun In Fundus

After the 3rd ocular migraine last week I finally caved and went to the ophthalmologist. It's amazing to me that in this day and age we still evaluate eye health with a bright light and a piece of glass. Really? You can tell whether or not my eyeball is going to stop working with that fancy flashlight and your magic glass circle? Pardon me while I scoff. All is well with the peepers, but the doc wanted to take pictures of a freckle on the inside of my right eye. Here's how it went down:

Mad Eyeball Scientist: I want to take photos of your fundus to document the size of this nevus.

Me (thinking): I bet you do, pervert! It's gonna take far more than your flashy lights and fashionable eye patches to persuade me to let you photograph this hot fundus. And you keep that nevus right in your pants there, buddy. I don't care what size it is.

Me: Uhhh....what's a fundus?

MES: It's the back of your eye. I assure you it's painless and quick.

Me (thinking): Yeah, that's what they all say.

Of course, this process is easier described than performed. The retina camera looks just like that doohickey that you stick your face into to test your eye pressure. Except instead of the eyeball-toucher, there's a camera lens. I thought "Hey, this will be a piece of cake!". That was, until he flipped it on and a blinding white light shot directly into my pupils. You can't yank your head back and start tearing stuff up in a rage. We are adults now and have to act accordingly. That didn't prevent he and I from entering this never-ending cycle:

MES: Look directly into the light and don't blink
Me: Ok. (Then blinks like a maniac)

After about 57 tries we finally got some hot sexy photos of my fundus. The Mad Eyeball Scientist was exasperated and I was nauseated and headachey. Kinda like all of my encounters with folks of the medical persuasion.

What I can't understand is how they can, in good conscience, send people out of their office to drive home after completely dorking up their eyesight. Isn't that kinda negligent? With my eyes dilated I could see up close, but not at a distance. If I put my glasses on, I could sort of see at a distance, but could not see anything inside the car. Neither of these scenarios seem like ideal driving conditions. Luckily for me (and the greater bay area), the route is memorized and these streets are nice and wide.