Why the Healthcare Insurance System is Broken

This is not a post specific to Nazareth, but it is very specific to me and since I'm in Nazareth and more than a bit upset I thought I'd share it (blow off some steam:-).

I've previously mentioned my utter disbelief at the frustration one can encounter when dealing with insurance (read it here), well, on Friday it went up a notch.

Last year in August I got a bill for roughly $6000.00 from Children's Surgical Associates, the doctor's group that has been providing medical care for my daughter for ten years related to her cleft-lip and palate. Upon receiving the bill I called the office and was told this happened rather often as the insurance companies don't understand how orthodontics are medically necessary. I was told it would be taken care of and thought nothing more of it.

I've been to the doctor every four to six weeks for progress checks since the procedure in May of last year (now over a year). Not once has an unpaid bill come up (excepting the conversation noted above). On Thursday, June 19 at about dinner time, we received an automated call from a company stating it was a debt collection agency and we had to call them at 1.800.860.4200 and ask for Mrs. Edwards.

I didn't get home until after 8:00 p.m., but was quite convinced this was a fraud and they wanted to capture our financial information. I did a Google search of the number and sure enough, there were more than a few instances of this number being left and telling people to call Mrs. Edwards (visit this site). I also came across one that included references to this company being fined by the FTC and having a case with the Commonwealth of PA (which was settled) (read the post here).

Clearly I'm thinking fraud. Friday morning, 8:30 a.m. we get the same call. I decide to call them and am astounded to find out that my doctor's group provided them the information.

I called the Billing Department and found out the person I needed to speak with had off on Fridays and Mondays, so I asked for her boss.

I explained my situation, she looked at my account record, and at first said they sent me a check for payment. I noted that was for the previous time when they threatened to send me to a collection agency for a misunderstanding between their office and the insurance. She agreed it was a different case and we moved on.

She then told me she would call the insurance and I asked that she do it while I was on the phone, since I had little faith in it being resolved without my hearing it.

She dialed the provider line. When the insurance rep was told I was on the phone, she said she couldn't speak to us - it was provider only. For some reason the provider couldn't also have the policy holder and person paying for the insurance. We asked who we could speak to and a number was provided. We called that number and were told we had to call the local, who would have filed the claim in the first place. Once we explained that the local wouldn't speak to us, we dealt in hypothetical scenarios. We learned the procedure was covered under my plan, but the local never submitted paperwork and therefore as far as they were concerned no claim had been filed.

I was assured this would be resolved. I asked if we could call the debt collection agency to clear my record. I was told no. They didn't have a phone number. They did everything by email. So I asked if I could be cc'd. Again I was told no, it was a privacy issue. I explained it was my privacy and was met with "I've spent too much time with you already." At which point I about lost what was left of my mind and accurately pointed out it was her job, not mine, to resolve this problem that was created by her employees for not following up and if anything was taking up too much of my time.

When she absolutely refused any additional help, I asked for her boss. He was in a meeting. Apparently it was a long meeting because despite leaving a voice mail on Friday morning I've yet to hear back from him.

I am extremely curious why a group of doctors would turn patients over to a debt collection agency without notifying them or reviewing why. I was told it is an automated process. They never check to see IF they should or if a mistake has been made. Given the quality of service I've now experienced on the support side of both the doctors group and insurance companies it is hard to believe we haven't all been locked up by debt collectors.

I can understand if a person stops making payment on electronic equipment or an automobile that you follow-up and then try to get your money by turning a person over. I'm sure certain industries have higher incidence of non-payment and it becomes a matter of process.

In this case we are talking about people, like myself, who pay inordinate amounts of money on insurance each month to pay for medical coverage, going to a doctors group at the Children's Hospital of Philadelphia (CHOP). The procedures are done knowing what the insurance coverage is and knowing whether or not a procedure will be covered. If it was a case where it wouldn't be covered, they'd know prior to performing the procedure. As such there is no reason to turn over anyone unless they knew they wouldn't be covered and then would be responsible for a payment plan. In those cases many who can't afford the procedure don't have to pay and those who do often receive a discount on the services.

CHOP was the first of its kind in the country, rated the top hospital in the country by US News & World Report for the past six years in a row, and led for many years by Dr. C. Everett Koop. Most people go to CHOP because they have to. Having the doctors billing office and insurance fail to work together and then send the parents of these children to be harassed by debt collection services on top of everything else they go through is really mind-boggling. It is no wonder our healthcare system is constantly discussed as having to be re-modeled. Our doctors, products, and equipment may be great, but it goes downhill from there. I look forward to significant change in the near future as it is much needed.

Congrats to those of you who made it to the end, a little therapy exercise on my part, the deep breaths weren't working, have a great day, looks beautiful out! And if anyone has any suggestions on fixing the overall mess our healthcare system is in, please don't hesitate to comment!