Tuesday, May 29, 2007

Understanding the system

Mrs. Gerbil is always after me to remember that not everyone knows how The (Managed Care) System works.

I usually regale her with at least two work stories each night. Sometimes I just need to de-brief a particularly stressful call; but more often than not the first line of my tale is, "Oh, my God, I had the most ridiculous call tonight." (It should go without saying that I never vent any identifying information--but there, I've said it anyway.) And then Mrs. Gerbil gently chides me for forgetting that the average person does not grok The System.

Hell, sometimes I don't even grok The System. But I will admit that I have a low tolerance for certain types of lack-of-grok, viz.:

Calling the emergency line for a non-emergency. It's 10:30 on Friday night and you have just realized that one of your claims was denied. You call the phone number on your insurance card, press 8 (a prompt clearly demarcated for emergency use only), and demand to know why your claim was denied. I will only inform you that this is a routine matter which is handled during business hours only. Perhaps hearing this will anger you; but unless your claim status poses a risk to yourself or others, it's not an emergency.

Calling the emergency line for a non-emergency matter which has nothing to do with mental health. You go to the pharmacy on a Satuday afternoon, and lo and behold, your co-pay for Lipitor has changed. You call your medical carrier, but they are closed. You hang up, call again, and select the prompt for mental health services. (Huh?) And then you press 8 and demand to know why your Lipitor suddenly costs $50. I will only inform you that you have reached your mental health insurance and we do not have anything to do with your prescription benefits. Perhaps you acknowledge that you just pressed prompts randomly to get a live person; but alas, I have no more information about your Lipitor than you do.

The guess and check method. You are calling about a hospital admission. You have not actually determined who the insurance carrier is, as you haven't bothered to look at the person's insurance card. So, you take a wild guess, and (because you are wrong) you think I should give you the correct information. Perhaps I do know whom you should be calling, and I might even transfer you if you're nice; but there is a reason that triage has already xeroxed the card.

I can't believe you just asked me that. If you work for a hospital, you should know how The System works. Please do not ask me to describe the difference between an HMO and a PPO. Perhaps you are new; but honey, this really makes my teeth hurt.


chip said...

You know, I don’t mean to be a jerk, but from someone who barely scrapes enough dough together every month to pay rent (all my cloths are wearing out and I had to eat leftovers so old they gave me food poisoning), having a claim denied is an emergency.

Lea said...

Dealing with the public is never easy. My mom's last gig, before retirement was at a telephone company where the people brought their payments / compliants in. Not only did she have to deal with the not so intelligent questions, she had to smell the people.

Gerbil said...

Chip, I appreciate your point about perspectives. But people call at off-hours about explanations of benefits (EOBs), not bills from providers.

There's usually a lag of a few weeks between the time someone receives an EOB and when he/she receives the corresponding bill from the provider. The provider is not going to come banging on the person's door over the weekend, because they're not in the office to receive their copy of the EOB and find out the claim's denied anyway. And when they get their copy, they'll probably call us too.

Therefore: although it can be extremely frustrating and upsetting when a claim is incorrectly processed (I've had this happen to me many, many times), it's not a clinical emergency. It may, however, be an urgent business matter. This (and a reminder that business matters are handled during business hours) is what I attempt to impress upon people who freak out at me because the claims department is closed. Just sometimes it takes several attempts.

(And, contrary to popular belief, no amount of yelling at me will bring the claims department back before their next business day!)

Chip said...

I understand. I just think that fear and anxiety, often quite justifiable, lowers one’s capacity to grok the difference between a clinical emergency and a non clinical emergacy.