Insurance Company Billing
Bill Long 7/15/08
A Lesson in Gobbledygook
We all love private companies in America because, as we all know, private companies are much more efficent than government or semi-public entities. They are efficient because the "bottom line" is at stake. Thus, we all know that private companies don't waste resources, because this would be contrary to the idea of wanting to maximize profit.
Ever hear someone say this? Now that we are in a political season, we may hear many people say this. I decided to test out that philosophy by following up on an insurance claim that I had made for a visit to an emergency room in a hospital about two months ago when I was out-of-state. My private insurer (I just sort of shudder when I utter that word private, as if the very utterance of the word assures quality and insight) is Providence Health Plans. I have been on board with them for about a year; actually I like them much better than my previous provider, so I am not complaining at all about the service that has been given me by various specialists (your vocabulary expands as you get older because you are forced to learn what all those medical specialists do...).
But here is the "Explanation of Benefits" statement I received from my private provider for that emergency service I needed about 1300 miles away from home. Though it has eight categories across the page, I will put them in vertical arrangement here.
1. Service Date -- in May.
2. Type of Service--Two kinds: Outpatient and OP ER/Urgent
3. Amount Charged--$390.25 and $238.26. Total $628.51.
4. Amount Allowed-- $0 and $471.38.
5. Amt. Not Covered-- $390.25 and $0.
6. Remark--none for the first amount; "BTN" for the second*
(a note below mentions that BTN stands for Provider Discount Applied. Of course, I can see how BTN stands for that, can't you?).
7. Deduct-- $0 and $0.
8. Copay/Coinsur-- $0 and $125.00
Then, at the bottom, is a statement saying "Amount Paid by Plan": $346.38; and "Member Responsibility": $125.00.
Discussion
I decided to call my provider, which answers questions more quickly than the Oregon Employment Department, to explain all these numbers. Many were confusing, like the difference between the sum of $346.38 and $125.00 and the bill of $628.51. I assumed, and was proven right, that this difference, a healthy amount of $157.13, was the amount not charged me because of a contract between my provider and the hospital, which gave me a 25% "discount." Indeed, the $157.13 is exactly 25% of the total charge. But nowhere on my explanation of benefits is this simple, and very helpful, point explained. They could have just put that in--there is even room for it on the line explaning "amount paid by plan" for a "contractual discount." Why couldn't they do that? I asked the helpful claims representative why "BTN" stood for "Provider Discount" and she said she wasn't sure. I asked her why the amount of $157.13 wasn't mentioned on the "Explanation of Benefits," to make things clear for everyone, and she said she didn't really know. She was a very pleasant person, however....
The Real Confusion
But the really confusing thing was when I tried to understand the "breakdowns" of the numbers. Why, I asked her, when considering the charge of $238.26, was $471.38 "allowed"? What did it mean that nearly twice as much was allowed as was charged? She didn't know. So, I had a few more questions like that, which she, in a most sprightly voice, also admitted not knowing the answers to. Then, after I finished, she did say, "Well, this form really is very confusing isn't it?"
Bingo. Confusing. So, the burden of these two essays has been to show that things not only are confusing, but that sometimes people act before they should and end up creating a mess. But it is relatively easy to remove confusion and to set up a system in which benefits are paid and clear explanations are given. Why can't someone just sit down and calmly ask if things make sense and, if they don't, argue for putting out a form where things are clear?
Conclusion
I used to think that my role in life was to understand and try to explain abstruse concepts from history, literature, philosophy and a variety of other fields to students or others in our world today. But, as I gradually discover my life in this world, I see that I live in systems where not only are the simplest things made devilishly complex by people, but that it really could be quite easy to develop a system to clarify things. And, I know it is true that many people, when facing confusion, will simply "give up."
Since most of life is lived in confusion (my thesis), and most of the confusion is unnecessary, I wonder if someone ought to be appointed as "chief clarifier" for things. I don't particularly want the job--I am content with just learning as much as I can about so many different things in the world. But it seems that someone, especially someone who believe that private entities are, by nature, efficient and good things, would dedicate him/herself to trying to make things clear. It, rather than Presidential rhetoric, would make a much better world...
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