Posted tagged ‘Health Insurance’

Health insurance hunter: secondary claims

May 15, 2018

I work for a small nonprofit organization in Hawaii, and it was eye-opening to enter the mysterious world of health insurance coding and billing. I gained a new appreciation for my doctor (aka primary care physician), my son’s pediatrician, my dentist, and my optometrist.

Earlier this year, I shared some stories about the sometimes confusing and frustrating health insurance claims process. But it doesn’t end there.

Some people have multiple health insurance policies. These secondary claims are tricky. The secondary plans often, but not always, pay the copayment or coinsurance (aka the “patient’s responsibility”). The secondary plans sometimes, but not always, pay for services that the primary plan does not cover.

Healthcare providers have to verify which insurance is primary. We have to verify which claims are forwarded (“crossover”) automatically, and which must be submitted manually. Sometimes we have to identify that there is a secondary plan, to avoid duplicate billing.

Some days I have to be a health insurance hunter, and other days I have to be a secondary claims health insurance hunter. Here are a few stories…

Why is there a payment and denial? The best insurance plans are the ones that automatically forward claims to the secondary plan – and let you know it upfront. We submitted a claim to Payer A1, and received a payment. Then we submitted a secondary claim to PayerA2, and received a payment – as well as a denial notice. Why? Because we sent a duplicate claim. That’s when we found out that Payer A1 automatically forwards claims to Payer A2.

The two copayments. We submitted a claim to Payer B1, and received a payment, along with a notice that the client had a copayment. The client paid the copayment. Then we received a payment from Payer B2. We didn’t know that the client had a secondary plan and we didn’t know that Payer B1 automatically forwarded claims to Payer B2. We refunded the client, with our apologies.

Why did they pay? We submitted a secondary claim to Payer C2, and received more than we expected. We immediately called Payer C2 to let them know about the overpayment, and set the check aside. Three months later, we received a letter saying that an “audit” uncovered the overpayment. Payer C2 demanded repayment – even though we never deposited the check – and threatened to deduct the amount from future payments, without apologizing for their mistake.

Why didn’t they pay? We submitted a claim to Payer D1, and received a payment, along with a notice that the client had a copayment. We submitted a secondary claim to Payer D2 for the copayment, but received a denial letter. Their explanation: the amount Payer D1 paid was more than the amount Payer D2 would have paid as the primary plan (even though Payer D2 is not the primary plan).

Are you satisfied with your health insurance plan(s)? Are your health care premiums affordable? What about your copayments or coinsurance?


Artwork courtesy of


Health insurance hunter

February 6, 2018

I work for a small nonprofit organization in Hawaii, and it was eye-opening to enter the mysterious world of health insurance coding and billing. Every medical procedure is reduced to numbers: provider account numbers, tax IDs, subscriber account numbers, dates of birth, diagnosis codes that prove medical necessity, and billing codes.

Sometimes, the confusing, frustrating, and impersonal claims process makes me long for a single-payer health care system.

Some days I have to be a health insurance hunter. Here are a few stories…

Who’s the payer? We submitted a claim to Payer A, but they denied the claim. Payer A said that yes, the client has insurance, the client had a “replacement” plan, and Payer B is responsible. Payer B said that yes, they are the insurance provider, but they are the secondary payer. We need to bill Payer C, and then submit a claim to Payer B.

There’s a lesson here: because of privacy issues, health insurance companies can’t share information indiscriminately. When there is more than one health insurance plan, clients have the responsibility to contact their plan administrators.

Where’s the claim? We submitted a claim to Payer D. Months went by, and we didn’t receive either a reimbursement or a denial letter. Payer D told us that the claim was rejected because of an error, but no rejection letter was sent. If we hadn’t called, we would not have known about the denied claim. We were able to resubmit the claim, and were eventually paid.

 Where’s the payment? We submitted a claim to Payer E. Months went by, and we didn’t receive either a reimbursement check or a denial letter. Payer E told us that we were “out of network” and that they sent a check directly to the client months ago. We didn’t know it, but the client was supposed to pay for the service out-of-pocket and Payer E would send them a reimbursement check. This has only happened twice so far.

Where’s the authorization? We submitted a claim to Payer F, but they required an authorization for services. We submitted the authorization request, but Payer F told us it was the wrong form. We submitted the correct form, but Payer F told us the provider number was wrong. We submitted the corrected form, but Payer F told us that another, optional part of the form was incomplete. Lesson:

What’s the deductible? Payer G denied a claim, and we needed to find out why. The claim was submitted correctly and the procedure was covered under the plan. We learned that the client had an annual deductible that has to be met before Payer F paid any claims. With health insurance premiums rising, many people (myself included) are moving to less expensive plans with higher deductibles. These deductibles are quickly becoming a serious problem for people with chronic illnesses or conditions.

Despite the aggravation, at the end of the day, I don’t think a single-payer health care system would be an improvement. It might be simpler, but it would be more restrictive and less flexible, because clients and providers would have no choice and little power to fight against denials and reimbursements.

Are you satisfied with the way your health insurance company works with your doctors? Have you generally had easy or frustrating experiences with medical claims?


Artwork courtesy of

Full circle about single-payer health insurance

February 21, 2017

Choose Your Health Insurance

I never understood why there is so much support for a national, single-payer healthcare system – until I started working in a small medical office.

Just last year, I believed that commercial health insurance is good for consumers. It is better for us as patients, in terms of flexibility (choosing the plan that fits you), choice (access to doctors you trust), and price (insurance plans must compete for your business, keeping their premiums reasonable and benefits attractive). It is better for healthcare providers, because they can choose which healthcare plans to accept; insurance companies with unreasonable requirements or low reimbursement rates could be avoided. Theoretically.

For healthcare providers, our current healthcare system can be a nightmare. Each healthcare plan has different copays, different deductibles, and vastly different levels of reimbursements. Some payers reimburse providers promptly; some payers may take months. It’s not fair to providers, who may have to wait a long time before they get compensated for their work. How many of us would go to work if we are not sure how much we will get paid, or when we’ll get a paycheck?

Even a small medical office, with a limited number of healthcare providers and billing codes, generates a lot of paperwork. Electronic billing helps, but there are still pre-authorizations, progress notes, requests for documentation, paper claims for payers who don’t accept electronic billing, and customer service phone calls to find out the status of a claim or why a claim was denied.

I’ve had problems with two insurance companies who each insist that the other is “primary” and should be billed first. I’ve had claims that get lost in the system, and then have to be “escalated” for payment. I’ve learned that military plans are “secondary” payers – except when they are “primary” payers.

For healthcare providers, I see the allure of a single-payer system: one claim form, one customer relations contact, one billing contact. Theoretically.

But the more I learn, the more I realize that a single-payer health insurance could be an even bigger nightmare than our current system. A monopoly on healthcare coverage, authorizations, and payments would not be good for anyone.

Consumers would have a limited choice of plans and providers, and under current law would be forced to buy health insurance that they may not be able to afford. Healthcare providers would have little recourse if the single-payer refuses a claim or underpays a claim.

In a short time, I’ve realized that the government health insurance payers (military, veterans, Medicare, and Medicaid) are the most difficult payers to work with. Government payers often take longer to reimburse providers – sometimes three times as long as commercial insurance companies. Government payers often pay providers less – sometimes 25% less than commercial insurance companies. Government payers often fall short in informing people that they need to have an authorization before they see a healthcare provider – and there is little recourse for appeals.

I was beguiled by the idea of single-payer health insurance, until I realized that the single-payer would be a government payer. I’ve come full circle, skeptical that single-payer health insurance would be an improvement over our current healthcare system.

If you work in the healthcare profession, what has been your experience with medical billing and claims? If you’ve lived in a country with a single-payer health insurance, what has been your experience with medical costs and care?


Clipart courtesy of


Gambling with our health in 2016

December 8, 2015

Health Care

Last month, I received a renewal letter for our 2016 health insurance coverage, and I was shocked to read that our monthly premium is going up over $200 – an increase of 34%. To be able to afford health insurance, we are downgrading our health care plan even more, with a very high deductible.

We are gambling with our wallets, hoping that we will be healthy in the coming year.

This is not the first time that our health insurance premiums have skyrocketed. In 2010, under the Hawaii Prepaid Health Care Act, we had a very good health care plan with our employer. Over the years, premiums slowly increased for our family of three, but we had time to adjust. Four years later, we felt the jarring impact of the Affordable Care Act: our monthly premium went up over $200 – an over 30% increase. Then, as now, we switched to a lower-benefit plan in order to afford our health insurance.

I know that health care is expensive. I know that the costs of providing health care increase every year. I know that we have access to good health care in Hawaii. And I just learned that Hawaii’s health care premiums are among the lowest in the nation, according to the Centers for Medicare and Medicaid Services.

Now I am apprehensive that next year when premiums increase, there is no other “basic” plan that we can downgrade to in order to keep our premiums affordable.

I thought that adding more people to health insurance plans would result in some economies of scale and cost savings in the long run. But in the case of health care, more demand results in higher costs.

Based on my experiences with health insurance in Hawaii, I have three suggestions:

Suggestion #1: We need to make health care premium increases more gradual. The Hawaii Department of Commerce and Consumer Affairs Insurance Division approved a 2016 rate hike because health care providers say it is necessary. A 20% or 30% increase isn’t affordable for most of us. I’d like to be able to limit the percent increase of health care premiums (and state taxes too). It all comes down to figuring out how we can make drastic rate hikes unnecessary.

What if we could limit annual health care premium increases to a set percentage or dollar amount? This would help us budget our money for the coming year.

Suggestion #2: We need access to up-front, published rates for medical and dental services. I would like to see doctors, dentists, optometrists, specialty-care physicians, clinics, and hospitals tell us the costs for services, labs, and procedures without insurance. This would help us compare rates and levels of service among health care providers, and figure out which level of health insurance works for us.

What if doctors decided to accept “cash only” (cash, checks, and credit cards) for services, and individuals were responsible for getting reimbursed from health care insurers? Would this lower the cost of health care, because doctors could focus on serving patients, instead of billing? Would this make individuals more proactive about preventative care and more cost-conscious about health care?

Suggestion #3: We need to move away from health care through employers. By linking health care with individuals, there’s no loss of coverage if we change jobs and we don’t need to rely on employers to make health care plan decisions for us.

What if we received a Health Care Card in addition to a Social Security Card upon birth or naturalization? We could automatically sign up children for pediatric medical and dental plans at the same time that parents fill out birth certificate forms.

Do you think that the Affordable Care Act has been good for Hawaii? How has the Affordable Care Act affected you?

Three more ways to encourage healthy living

August 2, 2011

The single most important thing we can do to encourage healthy living is change the health care insurance model. We need to take personal responsibility for our health, and we need health insurance that allows us, not our employers, to choose and purchase our health care plans.

Yes, I think we should have to pay for our own health insurance, hopefully with rebates or credits from our employer. But we would be covered when we are between jobs, and it would reduce or even eliminate the need for the government-sponsored COBRA.

Since I can’t change the health care industry, let’s talk about the things we can change, as employers and as individuals.

Health insurance companies already offer classes and seminars about healthy living. Some companies subsidize gym memberships, install exercise rooms, create wellness programs, and offer health care flexible spending accounts. There are numerous government programs to help you quit smoking, get free prenatal care, and lose weight.

Here are a few more ideas to encourage healthy living:

* Focus on winning health, not losing weight. In his book “A Simple Government: Twelve Things We Really Need from Washington (and a Trillion That We Don’t!)” (2011), TV host and former governor Mike Huckabee believes that we need to change the way we talk about health. Americans don’t like to lose and aren’t motivated by getting less of something. So instead of losing weight, reducing fat, and lowering our blood pressure, we need to win health, add muscle, and gain a healthy blood pressure.

* Offer premium rebates for healthy living. For example, Safeway’s voluntary Healthy Measures program (launched in 2008) offers health insurance premium rebates for no tobacco use, a healthy weight range, and normal blood pressure, blood glucose, and cholesterol levels. Guess what – it’s working! Safeway reports that 43% of participants who did not qualify for a 2009 blood pressure discount improved and received a rebate in 2010; and 17% of participants who did not qualify for a 2009 BMI (Body Mass Index) discount improved by at least 10% and received a rebate in 2010.

Offer lower co-pays and deductibles for healthy living. Nationwide Insurance offers drivers a “Vanishing Deductible” that lowers your deductible for each year of safe driving. Similarly, health insurance companies could offer lower co-pays for doctor visits and lower deductibles for out-of-pocket expenses, if people maintain a healthy lifestyle and a healthy weight.

I think that individual ownership of health care is the answer, not government-run health care. What do you think?