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More Outrageous Excesses From The Health Care Monster.......

The absolute worst thing that could happen to all the advances made under "Obama Care" is for us to let down our guard for one second....  

For those unfamiliar, I am an industry employee affiliated with one of the largest health care conglomerates on the planet.  I field calls all day from subscribers in an attempt to help them navigate their benefits and decipher their claims.

Make no mistake, the for-profit health care industry ( both medical providers and insurers) is one of the most prolific "loop hole" closing of any regulated business.  A hundred or more times a week,  I talk to desperate, often terminally ill people who find themselves caught between the hammer and anvil of their medical provider and their insurance company.

Part of the intent of this blog, sporadic as it may be, is to provide a venue where I can vent. If vicariously, another may gain some nugget of insight, some tangible evidence that the system is not only so broken it cannot be repaired but must be rebuilt from the ground up, maybe I can sleep better nights, not because I feel guilty in anyway for my profession, but because to be in possession of this type of knowledge and not share it, would be criminal.

Here, for your consideration, an absolutely true story

A subscriber recently called regarding the finalization of her claim for a visit to the local E/R.  She suddenly developed intense pain and blurred vision in one eye to the extent that she believed delaying treatment  with an attempt to schedule an appointment with a physician's office visit would or could result in further physical harm.  Incapable of driving herself, she  had the presence of mind to recall her policy excluded payment for ambulance service, period. With one hand holding a wet towel to the eye, she hit speed dial until she found a candidate who agreed to rush right over and drive her.

Let that sink in for a moment. Even in a genuine medical emergency, the savvy health care subscriber MUST be economically prudent  in order to avoid the after shock of potentially thousands of dollars in liability. Never mind her eye was spontaneously com- busting in its socket, the gorge of terror rising in her throat.

Upon arrival, the pain intensifying by the minute, the stiff an practiced professional intake people interrogated, photo copied, demanded the proper forms be filled before there was even a hope  of seeing a doctor. Soon though, she was wheel-chaired into an ante room, and eventually a doc who could actually do something began a cursory examination.

A solution to dilate the pupil with a trace of dye in it, was droppered into the eye. She was told the solution "would not sting" and in fact contained a numbing agent (medical cocaine derivative) to help alleviate her pain . Within a  second,  explosions erupted in the eye with what must have seemed like a close up view of a nuclear test.  The most unimaginable tendrils of pure pain wrapped around nerve, tissue and muscle, and there was a scream so guttural and primeval, she was unsure if its source was her own vocal chords. Something hauled her though the air and, as one who suddenly realizes her clothes are on fire,  the mind fumbles and adrenaline floods the neurons, propelling the body away- away from the pain the body in motion carries with it, and there is no place for stop drop or roll.

After she was subdued and the eye evacuated, painkiller injected with bright needles, the upshot was that the intern mistakenly juiced the eye with an ear cleaning solution designed to dissolve hardened wax.  

Now the "business end" of the story. The ever meticulous medical coders who rarely interact with either patient or doctor, reduce the reports into billable dollars by the judicious application of numerical codes. In this instance, the claim came in with all the appropriate codes that would indicate a diagnosis relevant to warrant an E/R visit, no issues there. Co pay? Check. Deductible amount? Not applicable. Provider status? Eligible for in network payment.

But under the codes indicating "medical supplies not otherwise indicated" both the eye drops AND the ear drops were being billed.  Additionally, all related "services" to correct the condition of said eye after almost permanently blinding this poor woman, were billed. The great machinery with which medical insurance claims are "processed" is not done by human beings, thus there seems at times, no applicable mode of logic in their adjudication. Claims software by design, looks for errors, exceptions, anomalies- in short, the software's "job" is to correctly finalize the claim based solely on accumulated raw data. In this instance, the application of ear drops to a human eyeball triggered the "medical necessity" flag, and the claim was denied...in full.

Sometimes, usually based on a set dollar limit, these claims are "held" by the software until a real person can hit an override button, correct any system errors, and manually process the claim. But in most instances, the claim is never seen by a human eye until it arrives in your mailbox or inbox, depending on what options you have selected on the insurance company web portal.  If you have opted for US mail, you are getting the finalized claim several days after the healthcare provider, who gets them electronically.It is not uncommon to get both the denied claim and an auto generated "balance due" notice from the provider at the same time.

Imagine yourself on the other end of all of this.......Then imagine yourself as me getting the phone call....

More later.................

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