For most of us who have health insurance (employer group, individual coverage, VA, Medicaid or Medicare), chances are we never see the bill from the doctor or hospital. It is sent directly to the insurer for payment. Isn't that nice!
Or is it? About six weeks later we may get a print-out from the insurer stating the bill amount, what the insurer paid, and what we as the insured may still owe. A few weeks later, a bill from the doctor 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 quite a bit. For what?
The bill never says and the statement from the insurer is likely to show only codes with some vague references. You saw one doctor for perhaps 15 minutes, but you get bills from six different entities all charging for that same short visit. That's how the game 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 off that same insurance. Did you actually receive the care for which your insurer was billed?
|The role of the adjuster
Several evening news magazine programs have run features on how medical providers through the insurers are ripping off the system. It happens in other types of insurance as well: bodily injury liability, medical pay or workers comp, but there is a difference. Supposedly, somebody is looking at all of those medical bills and thinking, “Hey, how does this relate to a broken arm?” How many X-rays of that arm were needed, and was a MRI or CAT scan really necessary? We call it “medical bill auditing,” but apparently the folks in the healthcare/medical insurance business never heard of it.
A good claims adjuster is supposed to stay on top of all of those bills and review them for accuracy, necessity, reasonableness and customary factors, even if the claimant is represented by counsel. (In those cases, we can't just sit and await the attorney's “package.”)
For workers comp, some states have schedules of what can be charged for various treatments. Charges have to fit the policy, including being incurred by an insured person. If a billing does not meet those criteria, it must be questioned. But apparently Medicare, Medicaid and Obamacare insurers don't have to do that. If they did, there would be phone calls to the insureds asking, “Did you see Dr. So-and-so on such-and-such a date? Were the following procedures performed?” If any of the answers are no, there is a problem that needs investigation.
How long an approved service goes on can also raise an issue. A licensed physician may prescribe “physical therapy,” which is not inexpensive. What type and for how many sessions? If all that is involved is a good massage with no kneading of frozen muscles or painful stretching, laborious exercises and ultrasound, an insurer'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 first three weeks, twice a week for the next two, then once a week for months, 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 claims adjuster earns $50,000 a year. If the Medicare/Medicaid and Obamacare programs are wasting billions of dollars paying for unnecessary treatment and medications, perhaps they need to hire a few thousand good claims adjusters to audit those payments. The savings would more than pay the cost of adjusting claims the correct way.
Ken Brownlee, CPCU, is a former adjuster and risk manager based in Atlanta, Ga. He now authors and edits claims-adjusting textbooks. Opinions expressed are the author's own.
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