The healthcare system in the United States is pretty complex, and the health insurance industry really piles on to an already confusing system. If you take this fact and throw in a fragmented business that provides employee benefits, it’s a recipe for massive frustration where one level doesn’t always know or even understand what the others are doing. If you’ve ever ended up in the unfortunate situation that my wife and I were in recently of having to try and figure out where something went wrong and why, it can be a daunting task to say the least. You may get bounced around while each person you talk to tries to pass the blame on other areas or even on you. You may even end up in billing hell.
I worked for a health insurance company for nearly 15 years. From this experience, I know my way around customer service and billing and how each area works behind the scenes – where all of the cogs in the machine align together. Despite this knowledge (or maybe because of it), though, there’s almost nothing that strikes more fear into me than calling my health insurance company when I need questions answered. The only thing worse is having to deal with them and a healthcare provider’s billing office.
Lost In The Shuffle
After losing my job in late 2013, my primary concern was getting onto the medical and dental insurance plans offered by my wife’s employer. Since getting married, we had always been covered under my employer, which just happened to be a health insurance company. However, once my employment there ended, I only had coverage for an additional month and a half following the day I was let go. Therefore, we were extremely careful to make sure that we completed all of the necessary forms and exams (e.g. health risk assessments and wellness statements) to be placed on her employer’s coverage at the best possible level of benefits.
Fast forward to late 2014, when we started receiving bills for some physical therapy that I’d had done due to a shoulder injury. The benefits, as they were explained to me by the physical therapist’s office, were that eligible charges would be subject to my plan’s deductible and coinsurance. For anyone unfamiliar with insurance terminology, the coinsurance is a percentage of the charges that you are responsible for after your deductible has been satisfied. For example, a common coinsurance percentage for plans that I’ve seen is 80/20% to $10,000. In this scenario, it means that once you’ve satisfied your deductible, you’re then responsible to pay for an additional 20% up to $2,000 (20% of $10,000). It’s also part of what’s referred to as your maximum out-of-pocket, which includes your deductible. This is the maximum amount of eligible charges that you are required to pay during one calendar or plan year. A healthcare provider’s billing statement should always match up with the health insurance statements for the same charges.
As a result of no longer having a second income, we were running tight on money. So we ended up paying at least $100 a month for what we were responsible for. This wasn’t too bad considering that the first bill was a little over $500. However, more bills rolled in over time. In keeping with what we’d been able to do, we continued to pay $100 or more a month in order to keep the bill collectors at bay. It wasn’t enough to prevent the provider’s billing office from calling every couple of weeks, though.
It wasn’t until September of 2015, almost a year after we received our first bill for my physical therapy, that I brought yet another recently received bill to my wife. She asked me how much the HRA (health reimbursement account) had paid being that we’d already paid out almost $1,000 at the time ourselves. This was a feature of our plan that I’d completely forgotten about until she mentioned it. One of the things we’d done when enrolling in her employer’s health insurance plan was complete what’s referred to as a wellness statement. This was something that had to be completed by our family physician and either faxed or physically brought to the employee benefits department within 90 days of enrolling.
Before we could get even start to get the latest bill figured out, we received a notice from a collection agency that the balance due had been turned over to them. They informed us that we had 30 days in which to either pay the amount in full or dispute the charges before they put a ding in our good credit history. At this point, of course, the race was on.
The next thing we did was contact the provider’s billing department to find out why the HRA monies hadn’t gone toward helping us with our out-of-pocket expenses. After speaking with them, my wife told me that they had said that they had nothing to do with that part of it. They only had the amount we owed and that amount had been turned over to collections, which they evidently do if bills are not paid within 30 days. They said that this was their standard procedure. However, there’s nothing on any of the billing statements indicating this and there was never anything received stating that they would be taking this action. Regardless, we had no luck with them in the end.
Next, we called the department that handles the insurance benefits for the company. After talking to a couple of people and being transferred a couple of times, my wife finally got through to someone who she was assured would be able to help her. We thought we were on the right track at this point, but ended up being told that they also did not have access to our HRA information at the time. The person with spoke with told us that they would do some research and call us back as soon as possible. We stressed that time was of the essence, though, being that a collection agency was now involved. She suggested going online and using the insurance company’s customer portal to log on and see if we could possibly get that information ourselves, although she thought that we may not be able to get the 2014 information there.
Sure enough, there was nothing online pertaining to our 2014 HRA benefits. I decided to call the insurance company and see if they could help. The customer service representative I spoke with was nice but seemed unsure at first if she’d be able to help. Not only was she unable to locate the 2014 HRA information, thus confirming what the employee benefits person at my wife’s company had told us, but she was also confused as to why the current calendar year information wasn’t showing up online for us either. After briefly placing us on hold, she came back and said it turned out that the employer had never funded the HRA for the 2014 calendar year. The account was set up with a zero balance, which was the reason there was nothing paid out to help offset our out-of-pocket costs.
We finally ended up getting a hold of the employee benefits person at my wife’s company once again to explain what we’d been told by the insurance company. She stated that she’d found out the same thing and the reason that the HRA was never funded was because they’d never received our wellness statements, which is a condition of being eligible for the HRA plan funding. To make matters worse, they did not keep any of the completed forms. Once they were logged into the system, they were disposed of. So unless our physician’s office still had a copy, which was highly unlikely, then there wasn’t anything further that they could do. In fact, even if we had been able to get a copy of the completed forms, she didn’t think that they would be able to do anything about it now anyway. When she asked why we hadn’t checked online to see that there were no funds in the HRA back when we got our first bill, I told her that we couldn’t even see the HRA balance for this year (which the insurance company did verify for us was there an funded for 2015), so what are the odds that it would have been there last year? That and the fact that I had personally forgotten about how the HRA portion of the plan worked until my wife had mentioned when we continued to get billed.
Billing Lesson Learned
In the end, we’re going to have to pay the rest of what they say that we owe them. It’s been quite a struggle just to get things figured out this far. However, we’ve learned a LOT about our benefits now. Especially what information to look for and where when we think that they might have messed something like this up again down the road. We’ve also learned that we need to double check and keep records and copies of just about everything, which we have never felt the need to do until now. Chalk it up to naivety and misplaced trust, I guess. In almost 15 years on the job, I had never gone through anything like this with my former employer either.
There has been so much debate, and rightfully so, about Obamacare and the Healthcare Reform Act. I just hope that all of the discussion that’s being generated can lead to solutions and better outcomes in the health insurance industry. Mostly, because there are people with far bigger problems than ours that truly need the assistance. I’m a man of average intelligence and a back ground in health insurance. If I can’t figure it out, then I can’t even imagine how confused some other people are.