Tuesday, March 20, 2007

Office Week

Pearl S. Buck:

The secret of joy in work is contained in one word - excellence. To know how to do something well is to enjoy it.

This week is office week. I managed to stay away from this blog for most of the morning and while I am in the mood to write,I have been procrastinating with the taxes and with medical bills and must tackle them now.

I had started out so organized (everything in it's place)but, now - everything is just piled in together. So I have to sift through all of that and follow up with the insurance company - because I KNOW mistakes happen.

"The Independent Urologist" (he's one of my urology links on my sidebar) has some interesting posts on his blog regarding insurance companies denying payment of medical claims to doctors. He is a urologist starting up his solo practice. I enjoy hearing his ideas (he's got some good ones) on setting up his practice (office and financially) and I find him inspirational with his financial ideas. He has other topics as well - the post on getting his child registered in preschool was a hoot. :) Another amusing one written by him is "Letter to the Editor" - January 11th, 07, but for this one you probably need an appreciation for medical codes and billing. :)

O.K., since I am plugging good posts - one more favorite of mine is Dr. Schwab's "Taking Trust" back from Oct. 7th, 06 and another "Vibrations" from Feb. 12th, 07. Dr. Schwab's Blog is "Surgeonsblog" - also on my side bar links. :) Also, if anyone is possibly facing any surgery, you should read some of his more recent posts which are packed full of good information.

The toughest claims to follow up on will be all the nonparticipating physicians (ED Docs, radiologists, and anesthesiologists) because my plan only pays them at 75 percent, but after some wrangling with the insurance company I found out that they will pay at 90% since they work in a hospital that participates with my plan. My argument being - How is it fair to penalize us for going to the provider on the plan by not paying 90% on claims across the board?

I don't have a choice as to which doctor to pick. I have to take the doctors that work for that hospital. By this I mean the doctors that actually do their work at the hospital,not the doctors that I see in their private practice.

The insurance company doesn't offer this info, but it turns out that they most definitely do pay the nonparticipating docs at 90%. I let it all slide and now have to go back through all of it. Believe me I have many EOB's to review along with the doctor bills to go through to determine who has been paid what amount. Then there will be many, many phone calls to follow up with.

I have to review everything going all the way back to 01/01/06. YIKES! It is going to be somewhat complicated. Oh well, you can't eat an elephant all at once...but you can eat it one bite at a time. :) I have found that I have to stay on top of them (which I didn't) because they continually revert back to the 75%. Fifteen percent might not seem like much, but multiply the large and small amounts of the 15% x number of claims and I know it will add up. Besides, Like Dr. Schnoor (Independent Urologist)says $50.00 pays your cell phone bill, etc,etc... and so I will be appreciative of whatever I can save financially.

Then when that is together call the various billers and make arrangements for payments. Some I can pay, but most have to go on a plan as I haven't been working now for quite awhile. Ah... this too shall pass. :)

At least this tax year (because of smaller income and med bills) I should at least derive enjoyment out of watching that little turbo tax calculator revolve in a favorable direction.

This morning my husband informed me that we didn't have any heat because we ran out of oil. We have lived in this house for 30 years, well as of September and we have never let that happen. I stopped automatic delivery because I have been shopping around for the best oil prices as needed. However the indicator on the tank must have broken and was giving a false reading. $620.00 for 249 gallons of oil! Later, I realized that the heat wasn't kicking on, checked the furnace and found water all over the floor and the furnace was cold. Sigh! I called Frey Plumbing & Heating (yes-that is a plug for a good company to anyone living in this area)and instead of coming out and charging for a service call, etc., he helped me trouble shoot while on the phone and it WORKED! He could've made money on that call but instead saved us money. Needless to say - they will have this family as a loyal customer from now on. :)

Time to dive back into my sea of paperwork! Hopefully, I will soon be back to work actually earning money, joyfully working in a medical environment of some kind. :)

Mark Twain:

What work I have done I have done because it has been play. If it had been work I shouldn't have done it. Who was it who said, "Blessed is the man who has found his work"? Whoever it was he had the right idea in his mind. Mark you, he says his work--not somebody else's work. The work that is really a man's own work is play and not work at all. Cursed is the man who has found some other man's work and cannot lose it. When we talk about the great workers of the world we really mean the great players of the world. The fellows who groan and sweat under the weary load of toil that they bear never can hope to do anything great. How can they when their souls are in a ferment of revolt against the employment of their hands and brains? The product of slavery, intellectual or physical, can never be great.


The Independent Urologist said...

Excellent post. Well written. Let me pick your brain. What do you think of this? Your surgeon is in network. The hospital is in network. The anesthesiologist, who you only meet the day of the surgery and you don't "choose" is out of network. Should you owe anything extra to the anesthesiologist?

SeaSpray said...

Hi Dr. Schnoor - Thank you for your kind words. :)

In a perfect world - NO.

How can that be fair? Of course, as you already discussed in your recent posts, insurance companies don't always seem to play by the rules - even their own rules.

A few years ago, I presented to the ED with a 6mm kidney stone lodged in the distal ureter. I know I don't have to tell you what an emergent situation that was. The only way to resolve it was to have a procedure in the OR to remove it.

The hospital is a participating provider on my plan. My plan pays 90% after plan adjustments with the participating providers.

However, that day - the urologist on call, the ED doc,the anesthesiologist AND the radiologist were non participating with my plan. YIKES! It is still the same for me today - they don't participate - well thank God my current urologist DOES participate.

So, my plan only paid 75% of the UCR fees on all of them.

Back then it didn't even occur to me to argue that. Even this year, I didn't start to think of it until June.

After I questioned this, pointing out that I am going to a hospital on the plan, the rep said we will pay the radiologists the extra 15% and they will be sent an additional check for the difference and they were.

Then some more bills came in and I realized this should apply to the anesthesiologists and the ED docs and called ins. co again. I spoke with a different rep who stated that only the radiologists would be paid the additional amount.

So, I persisted and she then said that effective in 2007, the ED docs would be reimbursed the additional amount but no other nonparticipating providers would be reimbursed at the 90% this year.

I politely, yet assertively persisted and requested a manager. She said she would send in an appeal. Guess what? My plan WILL reimburse a non participating provider at the 90% rate. Yay! I won that one.

Then...more bills..and they reverted back to the 75%. So, now I have to follow through with all of that.

Admittedly, I haven't read this year's 2007 ins manual, but I doubt that info is in there. This inquiring mind wants to know now and I will let you know if they have this in as part of their policy now. I doubt it!

My experience as a patient ties in with your experience as a participating provider. It would seem that we need to be ever vigilant in following up with the reimbursements, etc. and of course your end of things is so much more complicated.

I wonder if the reps are misinformed or are told to try to hang on to the money unless someone is persistent. I would think rules would be rules and that it would be black and white, but evidently there is a lot of gray area in dealing with these companies.

Also, I hope I am not coming across negatively as I am grateful to have insurance and for what they do pay.
I just know from experience that they do make mistakes.

I have even called them a few times questioning them in how they paid my surgeon because after plan adjustments it seemed like he got so much less than his initial bill. I STILL keep thinking it has to be a mistake and that coding or something was done wrong, but then I don't work in ins billing , so what do I know? The same with the hospital. I am floored when I see the hospital bill and then see how much less they are paid after adjustments.

Dr. Schnoor - do you think all doctor billing companies do all the things that you say you have had to to get reimbursed correctly? Do the doctors oversee them or do they trust the billers are doing the right things? After all - that is what they do - they bill all day long.

You know what? I feel sorry for the little elderly people or other people who are clueless about these things. I suspect people are paying more than they have to all the time. I am sure that I did.

Oh! One last thing. I am thinking that it is also logical to think that perhaps the insurance company should have reimbursed that first urologist I had who was nonparticipating at the 90% of UCR charges. My reasoning being that I did not get to "choose" someone on my plan, but that I had to have the urology Doc on call in the ED.

Oh well, water over the bridge.

Have a great day! :)

SeaSpray said...

What I meant to say was that I think the ins. co should have paid the additional 15% on the nonparticipating urologist that was on call in the ED that day that treated me for the big stone, but only for his treatment of me at the hospital.

Once I saw him in his private practice then I can see where it would revert back to the 75% and from that point could choose to go elsewhere - which i didn't anyway.

SeaSpray said...

Correction: I misspelled Dr. Schoor's last name. There is no "n" in his name.

Dr. Schoor - My apologies. :)