The Correct Words

In the medical world, we have our own language; well,actually multiple languages. The clinical has their languages, usually abbreviations, the medical administration has their own language, and the health insurers have their own language. Throughout my long medical administrative career, I have noted how incorrect language results in problems between health insurers and the medical office.

A case in point is this blaring headline from ProPublica:

“How One Employer Stuck a New Mom With a $898,984 Bill for Her Premature Baby”

The article was listing under a heading: “Health Insurance Hustle”.

 This is terrible, how could a medical facility and a health insurance company do this to a new mother with a critically ill patient?

A read of the article offers this tantalizing tidbit,

“Bard’s saga began, traumatically, when she gave birth to Sadie at just 26 weeks on Sept. 21, 2018, at the University of California, Irvine Medical Center in Southern California. Weighing less than a pound and a half, tiny enough to fit into Bard’s cupped hands, Sadie was rushed to the neonatal intensive care unit. Three days after her birth, Bard called Anthem Blue Cross, which administers her health plan, to start coverage. Anthem and UC Irvine’s billing department assured her that Sadie was covered, Bard said.” [emphasis added]

Right there in the paragraph, Anthem said the baby was covered. Mom took that to mean that baby was enrolled in the plan. This is a very common error on the part of the public. What Anthem meant by the comment was that the plan covered pre term births. What was not said by the Anthem representative, was that mom still had to go onto her employer’s website and enroll the baby in the plan. It had to be done in 31 days.

So, “Meanwhile, believing that everything with her health benefits was on track, Bard spent nine of those first 31 days recovering in her own hospital bed and then had to return to the emergency room because of a subsequent infection. She spent as much time as she could in the neonatal intensive care unit, where Sadie, in an incubator, attached to tubes and wires, battled a host of critical ailments related to extremely premature birth. At times, doctors gave her a 50-50 chance of survival.”

Mom thought everything was fine with her insurance, so she focused on her baby. “Then, eight days past the 31-day deadline, UC Irvine’s billing department alerted Bard to a problem with Sadie’s coverage. Anthem was saying it could not process the claims for the baby, who was still in the NICU.”

Then the bills begin to arrive, totaling almost One Million Dollars. Through the efforts of Social Media, the insurance company relented and retro activated the baby’s enrollment back to her date of birth.

This could have been so easily avoided if both mom and the insurance company had simply clarified what “covered” meant. Any reasonable person should know that you simply cannot call your insurance company and you or a family member are magically entered. It takes some effort on the patient’s part to make that happen.  

The most common complaint that I receive from patients regarding a bill is, “The Insurance Company said you coded wrong”. No, we did not code wrong.  You, the patient, presented with a flu during your Preventive Exam so you were billed for an office visit.

Or, “Why did I receive this bill, my Insurance Company said I was covered.” Yes, you are covered for that service, but not by this provider.

In medicine, as in all businesses, it is imperative that the consumer, the patient be aware of what they are asking. Insurance Companies Representatives are limited as to what they can tell a patient, so when calling your insurance company, make sure that you are both speaking the same language.