The Right Thing

I have been working in the Health Insurance industry for 9 years, this is an industry that has its own language and rules and is very confusing for those who don't speak "health insurance"

Many people know that they have insurance they may not understand their plans but they have it and use it, receive EOB's (explanation of benefits) in the mail when a claim has been processed, most toss them and some hang onto them since they know that they are important.

On any given day I answer questions for many of the member's of the health plan I work for and walk them through the way a claim was processed. Most of the time they are happy with what I tell them, with a few instances of people being angry because something wasn't covered.

When I had Adrianna in September I had a c-section which require not only my doctor but also an assistant surgeon. I knew this going into the procedure as this was my second c-section.
Adrianna was born on September 9 at 9:58 AM - the atmosphere in the OR was so fun, the anesthesiologist was cracking jokes, Dr. Whitefield (my doctor) was talking about his trip to Brazil, the assistant surgeon was talking about Mexican food she had for dinner the night before. At one point I looked at Joe and said "I hope that they don't forget the task at hand here" he just laughed. They remembered because my beautiful daughter was born with out any problems, beside the cord being around her neck 3 times.

I had a wonderful recovery at Providence Alaska Medical Center, the care was great and the nursing staff top notch.

In November I received a bill from my doctor's office that stated I owed $447.18 for the assistant surgeon fees. I pulled out the EOB that I had from my health plan to see what they had paid. I was covered at 100% at the time Adrianna was born and should owe nothing. The EOB showed the total billed was $1435.00 for the assistant surgeon my health plan paid 25% of the surgeon's fee (standard payment for any asst. surgeon) at 100% so my health plan paid $987.82. Now standard practice is that the amount that was denied as assistant surgeon reduction is written off and not balance billed to the patient, so I ignored the bill in November.

In March I received a statement from my doctor's office showing that the balance owed for the assistant surgeon was +120 days and now due. I called and spoke to the billing office and was told that they were not networked with my health plan and that I would be responsible for the denied amount. They also said that they bill 35% of the surgeon's fee for assistant surgeon. This surprised me as I was expecting the balance to be written off as it had been when I had Quentin in 2004 and as is the standard. I politely said thank you to the billing clerk and hung up.

Red flags were going off all over the place in my head because of my background in insurance. I knew that the industry standard is to bill 25% of the surgeon's fee and that the patient should not be balance billed. I also knew that in Alaska we do not have a network and our plans are written that we can see which ever doctor we want to see without being penalized.

I thought a bit and decided that I would write my doctor a letter. I have learned through dealing with the pediatrician's office that the doctor's don't always know what is going on in the administrative part of the office. I had a feeling that Dr. Whitefield didn't know that the policy his office was using was outside the standards in both the community and the industry and was penalizing his patients financially.
The worst that would happen was that I would have to pay the statement, the best outcome would be that the office would do the right thing and write off the balance owed.

I composed a letter directly to my doctor explained the situation and requested as a long time patient of the practice (10 years) they adjust my bill. I mailed the letter out on March 13, 2009.

I waited for a response, I was pretty sure that Dr. Whitefield would call to discuss my letter with me. Saturday Cassie from the billing office called and said that Dr. Whitefield had received my letter and that my balance was zero - they wrote off the reduction amount. I said Thank you, and her response was that it was the right thing to do.

So the moral of this long story is that if you have questions about your bills and you don't like the answer you get from the billing office go directly to your doctor. Also since I know a thing or two about health insurance and all kinds of plans please don't hesitate to call or email me with a question that you have - I will do my best to help figure out the issue.