OK

I work on behalf of one of the largest health care providers on the planet.  I'm a front line agent for members who call in with questions about their coverage or claims. Today I had a call that floored me and believe me when I tell you, people who do what I do have "heard it all."

It isn't that one ever becomes callous. A good majority of issues I deal with are a direct result of members not taking the time to try to understand their benefits, which I readily agree are tedious and confusing in the first place. That's where I come in.  The most difficult calls are those made after the claim comes in. It is bascially too late at that point and a failure to understand about deductibles, co-pays, coinsurance, referrals and primary care physicians are the progenitor of most post service complaints. I am limited at this point.

But then there are situations such as the one that occured today. I wish I could say they are rare, that they are the exception. The industry of for-profit health care is an adversarial one. The insurance company can only increase profits in one of two ways:  adding new members or denying claims of existing members Many claims are denied routinely for errors the provider makes or for failing to get "pre authorization." Most of them stay denied. A good many are denied based on pre existing conditions and these sadly, are almost never reversed.

Mainly it is the individual member who is left with what can sometimes be a staggering amount of money he or she is legally responsible for depsite the fact that the member had nothing to do with the reason the claim denied. Today I got call from a 47 year old male member who recently recieved inpatient services for major depression and suicidal ideology. Thankfully and fortunately, this man had the fortitude to reach out and seek help. He was able to get pre approval for treatment based on his benefits and diagnosis. He doubtless was at a point in his life where, for whatever reason, desparation had so clouded his perception, that the thought of taking his own life seemed viable. I cannot imagine what it took for him to undergo the exposure he had to endure in order to satisfy the people who "pre approve" such services at my company.

But perhaps after he did so, he may have felt a spark of hope. The insurance policy he had so faithfully and diligently paid for all these years was a real "life saver." Maybe his state of mind was such that he may have felt this was one of the only "good decisions" he had made in awhile. I cannot say. But when I spoke to him this morning, his was the abject voice of defeat. The claim for the inpatient hospital stay on which he had doubltess staked his last good, hope was denied a full two weeks after he was released.

There is no law either locally or nationally which prohibits a medical care provider from "billing" any amount they desire. When an insurance carrier is involved however, a negotiated rate is paid if the claim is approved. If it isn't, many times the member has little recourse against payng the full amount. In this case, a six day inpatient stay at the hospital came to a little under $45,000.00, or just about what the median annual income would be for a family of three. He was already getting calls from the hospital.

It is necesarry here to divert the reader for a moment. Claims and insurance billing is a filed of expertise in its own right. Medical coding is a complex endeavor. The primary coding for all insurance claims is the "diagnosis code" or "ICD-9 code which Medicare usues as well as all insurance carriers and medical providers. the correct oir incorrect code means simply, approval or denial of the claim, period. 98% of insured persons have little knowledge of coding and its impact on their claims until AFTER they experience what this member did.

In 2009 with the economy teetering on disaster, the wise and forward-thinking folks from the medical coding complex, intitated a brand new diagnosis code: V 62.0. These codes are for inputting on claims for remibursment. These codes are affixed to death certificates as well. These codes are stored on every insured person in the country and are often used to deny claims based on a pre existing condition.  

ICD 9 code V62.0 is rendered as follows: diagnoses in this category are "those circumstances or fear of them, affecting the peron directly involved or others, mentioned as the reason, justified or not, for seeking or receiving medical advice or care."  The particular and distinct code of V62.0 is this: Economic. Unemployment. Poverty. Lacking means of adequate support.  This is a valid and recognizable medical diagnosis. Mainly the member never knows what diagnosis codes have, are, or will be attached to his or her name. If after reading this however, you would like to know how to find this information on yourslef, let me know.

My caller had no idea this code was attached to his pre approved inpatient hospital service. And by Federal law, I could not disclose this to him either. My company duly denied this enitre claim predicated on the inclusion of the code V62.0 as "no benefit available for service rendered."

Look if at this point, whoever you are, you have any reservations about how desparately the for-profit insurance industry in this country needs to be torn down and rebuillt, consider the example cited here. I assure you it is 100% real life. I assure you further, it is indeed a matter of life and death.  

If on the other hand, you are outraged, feel free to share and comment on this diary. Please also feel free to contact me.

8:24 PM PT: I did not mean to intentionally create a "riddle". The enitre claim was legally denied based on the fact that the inclusion of a diganosis not mutally agreed upon prior to services, was considered a contractual violation. i do not believe the provider did this intentionally. However, prevailing insurance laws give the proivder the right to puruse the member for collection


EMAIL TO A FRIEND X
Your Email has been sent.