Out There

seguransa madness!

Posted in commercial by Pete on October 13, 2009

Insurance companies.  Necessary evil or just evil?  I’m an anal, detail-oriented person whose favorite job was doing accounting, but I despise dealing with our insurance company.  We pay people money so that we don’t have to pay a lot later, and their job is to deny/minimize those future claims whenever possible, and our job is to monitor, harass, beg, cajole, and threaten them into paying what they’re supposed to.  Who thought this up?  The kingdom won’t be like this.  Heck, CANADA isn’t like this.

So, the reason for this post is my total confusion regarding my current insurer’s policy regarding double coverage.  This will be a long, boring post with lots of photos of boring stuff.  The only ones who could care about this are those who work in the field or who find themselves in the belly of the beast as I am now and turn to google in desperation.  Here are some photos of “explanation of benefit” (EOB) statements from a doctor visit in April.  At that visit, we paid $30.30 up front since our plan usually requires us to pay 90%.

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So for those of you scoring at home, the total due is $303, $51.87 of which Premier (our insurance company, aka PCA) says “exceeds usual & customary.”  Of the remaining $251.13, they apply a $10 deductible, then pay the rest at 90%.  My wife is the one who went to the Dr, and this is applied to her insurance.  Then check out the EOB below, which is applied to my insurance (same insurance company, same employer, same benefits, etc).

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So if you can’t read that, the total due is $303, $51.60 of which “exceeds usual & customary.”  No idea why the amount that exceeded usual and customary changed slightly.  Of the other $251.40, they apply the annual $150 deductible, and then pay $85.98, which they claim is 90% of the remainder (even though it’s not – it’s just the amount needed to get to $303 in total).

So taken together, they applied $160 to deductibles AND paid the full $303 despite the fact that $51 and change exceeded usual and customary.  Is that normal?  Plus we paid $30.30, and haven’t seen any refund.

Fast forward a few months to a dental visit.  This one also has charges that exceed usual and customary, but they’re not picking them up this time.

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Tammy is again the patient in this example, and the above is her EOB statement.  Below is the same thing, but applied to my insurance.

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So why did they pay the charges that exceed usual & customary in the first case, but not this one?  Our dentist sent us a bill for the $65.69 for each of the 3 of us, and I’m unsure whether I should pay the dentist or try to get the insurance company to pay it.  Some of our other medical providers will write off the amount not covered by insurance that is labelled as exceeding “usual & customary,” but not apparently in the case of Dr Nick Feldman!  Who, I must say, although it was only one visit, appears to be a superb dentist.  In addition to the usual stuff, the guy takes digital pics of each of your teeth from 3 different angles, and you watch it all on a color monitor – even with Claire they let her hit the button to take each picture – she left the dentist at 38 months thinking that going to the dentist is fun fun fun.

About now you are thinking “What a huge waste of time.  Did you consider CALLING the insurance company??”  Yes, I did and spoke with a woman there for literally like over an hour trying to make sense of the 4/30/09 EOB statements.  We got nowhere.  She was very nice and professional and patient, but we just repeatedly missed each other and both left the conversation very frustrated.  She even called me back at home (unexpectedly) a few minutes after we hung up and we went around again for like 20-30 more minutes, me asking earnest questions 10 different ways and her endlessly explaining but to me she was not understanding my questions and answering questions I hadn’t asked and repeating the same information every time.  The conversation ended with her basically saying she has lots of work to do and can’t spend all day repeating the same information to me that I can’t absorb.

Much of the confusion is because for the last 5 years Tammy had the only job and all our insurance was through her.  But for the 14 months since that time we are both working for the school district and have dual coverage.  And a big part of the problem I think is that our medical plan book that has all the details doesn’t have a section on dual coverage that spells out how it will work.  Another factor is that we have significant history with this company with lots of mistakes in their payouts, like an average of a couple errors per year probably, to the point that I keep all the charges from all the EOBs in 3 big excel spreadsheets.  Tammy adds that another reason not to trust them is that our insurance company changes its name every 6 months and is based in Reno, NV.  : – )

I have to admit that this probably WAS a total waste of time, but for whatever reason I was compelled to do it.  Now I can just send an email to Premier with a link to this blog post and not have to explain it all in the email.  ; – )  So for all of you insurance experts – do you have any insight for me?  Am I screwed up or is it them?  Should I pay the dentist?

****UPDATE as of 10/22/09****

I called the dentist to schedule a visit for a new crown I need.  I asked what my balance was, and they told me zero.  Apparently PCA paid my entire bill, including the $65.69 that exceeded usual and customary rates (UCR – I’m learning the lingo here).  So I took the plunge and called PCA.  They sent me to the same poor woman I spoke with at such length before.  I’m sure she remembered me, or certainly did after a few minutes.  She explained that they paid the eligible expense on mine at 70% (because I’m in my 1st full calendar year with LKSD, it goes up year by year by 10%), then they coordinated it with Tammy’s coverage, which paid 100% of what was left, including the amount that exceeded UCR.

So my question for her was how come they didn’t coordinate Tammy and Claire’s visits with my coverage so that mine would pay 70% of the amounts that exceeded UCR from their appointments?  She couldn’t get it, but was convinced that I wasn’t understanding her repeated explanations.  She was unfailingly polite and patient, and it really pains me to email or call PCA and ask for anyone but her in order to get this resolved.  I think she is assigned to our company, so we’re sort of stuck with it.  It may well be that they have a solid rationale or explanation, but I didn’t hear it.

So now it’s some time later and I called them and asked for anyone but the first person and was directed to Suzi.  She listened well and after 10 minutes of explaining and some confusion she spoke with her supervisor with me on hold for 5-10 minutes and then came back on and said I was absolutely right, it was inconsistent and the amounts in excess of UCR should always be paid by the other spouse’s coverage at whatever their coverage is (in my case 70%).  So instead of owing $65.69 on each of Tammy and Claire’s accounts with Dr Feldman, we’ll only owe 30% of that (about $20) after PCA coughs up their 70%.  In a diplomatic way she closed by saying that things aren’t always as consistent at PCA as they’d like and they’re working on it.  I’m thrilled, not for the $90 or whatever they will pay, but that there is an end to this long story.  Speaking with that first employee was like being on the eternal treadmill elliptical of insurance futility.  And the worst part is she was as nice as your grandma so I can’t hate her.