For most of us who have health insurance (employer group, individualcoverage, VA, Medicaid or Medicare), chances are we never see thebill from the doctor or hospital. It is sent directly to theinsurer for payment. Isn't that nice!

Or is it? About six weeks later we may get a print-out from theinsurer stating the bill amount, what the insurer paid, and what weas the insured may still owe. A few weeks later, a bill from thedoctor or the hospital arrives with a very short “pay by” date.This includes any deductibles, co-pays and, more importantly,amounts in excess of what the insurer covered. Too often it's quitea bit. For what?

The bill never says and the statement from the insurer is likelyto show only codes with some vague references. You saw one doctorfor perhaps 15 minutes, but you get bills from six differententities all charging for that same short visit. That's how thegame is played – you don't see what is being charged for your care,and the service providers (physicians, clinicians, X-rays,pharmacies, therapists, pathologists and specialists) each feed offthat same insurance. Did you actually receive the care for whichyour insurer was billed?

The role of the adjuster

Several evening news magazine programs have run features on howmedical providers through the insurers are ripping off the system.It happens in other types of insurance as well: bodily injuryliability, medical pay or workers comp, but there is a difference.Supposedly, somebody is looking at all of those medical bills andthinking, “Hey, how does this relate to a broken arm?” How manyX-rays of that arm were needed, and was a MRI or CAT scan reallynecessary? We call it “medical bill auditing,” but apparently thefolks in the healthcare/medical insurance business never heard ofit.

A good claims adjuster is supposed to stay on top of all ofthose bills and review them for accuracy, necessity, reasonablenessand customary factors, even if the claimant is represented bycounsel. (In those cases, we can't just sit and await theattorney's “package.”)

For workers comp, some states have schedules ofwhat can be charged for various treatments. Charges have to fit thepolicy, including being incurred by an insured person. If a billingdoes not meet those criteria, it must be questioned. But apparentlyMedicare, Medicaid and Obamacare insurers don't have to do that. Ifthey did, there would be phone calls to the insureds asking, “Didyou see Dr. So-and-so on such-and-such a date? Were the followingprocedures performed?” If any of the answers are no, there is aproblem that needs investigation.

How long an approved service goes on can also raise an issue. Alicensed physician may prescribe “physical therapy,” which is notinexpensive. What type and for how many sessions? If all that isinvolved is a good massage with no kneading of frozen muscles orpainful stretching, laborious exercises and ultrasound, aninsurer's money is being wasted. Some medical expense involves“hands-on” treatment, perhaps with expensive herbal remedies added.Such care often consists of three “treatments” a week for the firstthree weeks, twice a week for the next two, then once a week formonths, and at the end the patient is rarely “fully recovered.”There is always that lingering pain that cannot be cured, with no“maximum medical improvement.”

According to the U.S. Department of Labor the average claimsadjuster earns $50,000 a year. If the Medicare/Medicaid andObamacare programs are wasting billions of dollars paying forunnecessary treatment and medications, perhaps they need to hire afew thousand good claims adjusters to audit those payments. Thesavings would more than pay the cost of adjusting claims thecorrect way.

Ken Brownlee, CPCU, is a former adjuster and risk managerbased in Atlanta, Ga. He now authors and edits claims-adjustingtextbooks. Opinions expressed are the author's own.