Friday, April 1, 2011

Communication gaps, incompetence, and healthcare systems

So here's a story of an immediate experience this morning that relates to the conversations we have been having about structural barriers. As I share this story, let me first share that I am a health communication scholar with a graduate education and with almost a decade of experience listening to stories of individuals, families, and communities about their experiences with healthcare. On one hand, I believe that my education and scholarship have given me the skillsets to ask questions, to engage critically, and to push the envelope; on the other hand, I also believe that I miss many opportunities to ask questions, simply because of the length of the interactions in the provider's office.

Today's experience that I will share with you relates to billing. So we had gone in to the physician at one of the Arnett locations for a regular physical. The co-payment was made at the counter ($15), and we walked away with the assumption that the rest of the bill ($128 as I would come to learn later) would be taken care of as that's what happens with our CIGNA insurance we have had (Note that Purdue as well as I pay pretty heavy premiums for this insurance).

Two months later, CIGNA had sent a claims detail noting that it was not going to cover the bill. The explanation of benefits form noted the trip to the physician's office as not being covered by CIGNA and put the alphabet A by the note. In a footnote, it stated in capital letters "YOUR PLAN PROVIDES BENEFITS ONLY FOR COVERED EXPENSES FOR TRATMENT OR DIAGNOSIS OF AN INJURY OR ILLNESS." Now what had changed so dramatically from our last visit to the physician for a physical? How was it that the yearly physical was now not being covered? Although these questions occured to me when I received the note from CIGNA toward the end of February, I did not find the time amidst my work schedule to call up CIGNA within the regular business hours.

This morning, we received a bill in the mail from Clarian Arnett that stated the remaining $128 needed to be paid by the patient, and that the patient amount was due now. The note stated "The balance due is your responsibility. Please pay the entire balance due upon receipt of this statement or contact our office immediately if you cannot make payment in full. It is our policy to refer delinquent accounts to a collection agency. Your assistance in resolving this bill is appreciated. Please disregard this notice if payment has already been made." The statement from Arnett was frustration causing to say the least, as this was the first time I was seeing this, and there was no room for acknowledging a billing error. The implicit assumption in the message was that the patient was at fault for not having the bill. Also, the threat of sending the account to a collection agency was explicit.

So I opened up my schedule to call up CIGNA and speak to the claims department at CIGNA to ask why the claim had not been covered. After pressing through eight different buttons and providing information/making choices, I got to a CIGNA staff member. The CIGNA staff member noted that the category that the claim was filed under by Arnett was not covered by CIGNA under our plan coverage. She assured me that she would send the file for research and took down my number to reach me at. Now this was a plain and simply physical I thought, one we have been diligently having every year and that has been covered in the past. So what had changed? I pulled up my coverage information on the benefits website and from the site it seemed like nothing had changed. Armed with this knowledge, I called back CIGNA. Now when I spoke with the CIGNA staff member and shared the information that physicals are supposed to be covered by my CIGNA plan, she informed me that the code under which the information was entered was not a physical, and this specific code was not covered by my CIGNA plan. So unsure about what a code is, I asked her to explain. She noted that this is something that is entered by the doctor's office at Clarian Arnett and suggested that I speak with Arnett.

After hanging up with CIGNA, I pulled up the bill from Clarian Arnett and called the billing line. After referring to the account number and service date, I got to a billing clerk who stated that she worked for IU Health (Arnett is now IU Health). The billing clerk noted that the claim had been denied by CIGNA because it was not covered. She used terms such as EFR and code, and stated that the code entered by the staff at the clinic did not stand for a phsycial. So what was this EFR and the code? I asked for clarifications again, and she noted that this is information that is typed in by the provider's office. But wasn't she at the provider's office at Arnett? After a few back and forth exchanges trying to clarify the bill and the coding process, she said that she will send the bill back for research (by this point, I am confused about what research really means to her as to me, research seems to be the catch-all term) and then have it reviewed by the doctor's office to chek on the code under which the service was entered. She apologized for the inconvenience and noted that Arnett will get back in touch with me.

I thanked her for her apology and understanding, and asked her what Arnett was going to do to be proactive about fixing the problem, and also about making sure that the problem does not happen again. I also asked her where I could note down my complaint officially and how could this complaint be made visible to other patients chosing Arnett. I also asked what remedial measures her organization would take. I did not get a satisfactory answer from her, as probably I believe she is not really positioned within the structure to answer the questions I was asking. She did note that she will bring it to the notice of her supervisor. I asked her that I would like to be called back not only with the information about how the billing issue has been resolved, but also with information about the proactive steps Arnett would take organizationally in addressing the so-called billing errors (as this is not the first time that I have had a billing misunderstanding with Arnett).

The incident this morning raises many important questions. Whereas on one hand, the consequences for not paying the bill are threats of the account being sent to a collection agency, what are similar consequences for healthcare organizations? What are the consequences for Arnett for instance for its incompetence, failure of communication, and so called billing erros? The morality of forgiveness here takes on an unequal narrative. When the patient for instance has not made a payment, he/she is threatened with the threat of being sent to a collection agency. What are the consequences of the billing errors on the part of hospitals and health organizations? What are the magnitudes of these consequences and how do they match up? What would be the equivalent of a collection agency for the health organization that stands to negatively impact its operation, reputation, credibility, and economic viability? Is the apology enough when the health organization has taken up 2 hours of your work day? Who is paying for those 2 hours? When we calculate the cost of healthcare, how do we meaningfully take into account the number of hours and the amount of labor that go into patients attempting to clarify billing issues? And even most importantly, what happens with patients who simply do not have the resources to spend 2 hours on the phone with the health insurance and the healthcare provider?


Nadine said...

I had the same experience but with Sigma Group. The code used by the service providers and the insurance companies can mean you are denied coverage. I wasted days trying to resolve the problem and playing the role of the middle person. Some people simply pay it out of fear or lack of information. I am hoping someone will research the absurdity of signing consent forms before receiving healthcare. There is nothing voluntary in it.

Samiran said...

The plutocracy called America. No wonder my own experiences with doctors have been less than satisfactory in US compared to that backward and primitive land called India, where doctors still believe in listening to the patients and are in general more inclined about their welfare than the hourly money they are making.
Though I'm sad to say, India has been quickly degrading to the levels of US. The obscenity and lust for money displayed by doctors in some of the cases that I hear about nowadays almost parallel levels seen here in US.

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