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The Art and Confusion of Commercial Billing: Transparency is missing!

Commercial Insurance Coverage for Hearing aids is Convoluted at best! 

Being a small private Audiology practice in a busy city has its ups and downs.  I have to admit that one of the downs is dealing with Commercial insurance companies or non-Medicare/Medicaid coverage.  And this is not just a downer for us as a small practice but also for our patients.   There is a serious lack of transparency which causes both our patient and us to get a little on edge.  Now I am just an audiologist and like to help people hear better so this is the perspective of a clinician trying to figure out  business stuff, payments of insurance, that is convoluted and not my favorite thing to do!

VERIFYING BENEFITS:

OK, that being said, the first issue is verifying benefits when people come to see us.   My front staff does this for all of us and we have noticed that If you call a few different times, it is possible that you will get a few different stories on benefits.   Eventually you have to stick to one story and explain it to our person coming to see us.   We recommend that the person also call insurance to verify and may call and verify to get the story again.   Sometimes none of the stories line up on the benefit.  We tell our people coming to see us that what was told by the representative could be wrong.  Now they have less experience than I do in dealing with getting their benefits and some people believe that what they are told is golden.    We of course need to make sure they understand that it isn’t golden so they are not upset when and if another bill is presented to them.  This sometimes can start off some animosity from the patient and creates a block for us to do what we do best, help people hear better.

Sadly, a few of our people who want to work with us don’t like the reality of uncertainty and so they chose to go to a larger establishment as they feel that will do them better.  Why is that different you ask.  Well it is different because now the provider doesn’t have anything to do with the benefits or the business so there is peace.  Until, the billing department comes to the patient for more money.   We hear about that from people who left the big establishment because of that lack of connection.  So you see, either way, whether a big establishment or a small business, the patient doesn’t always get what they want.  We lose people and the big establishment doesn’t have connections.

Continuing on with the Verified story:

So now we stayed to one benefit story for our patient and the patient understands and we understand that there is no certainty of anything.  We work with the patient for better hearing and this is all fun.  We have come to a nice solution and everyone is satisfied with the clinical service.  We submit the HICFA form.. which is the electronic billing form to the insurance company essentially.  The insurance company can do two different events at this point.  They can accept the form as it is billed right, or they can spit it back out and have you re-submit.

Trying to get the Benefit for our people:

After getting it to be accepted we all wait to see what we will get.  A couple different scenarios can happen now.

First and best scenario, they pay exactly what they, the insurance company said they would pay!  Everyone is happy!

Second scenario, The insurance company pays nothing as it wasn’t billed right and we have to resubmit again!  The insurance company does not tell you how it should be submitted.  The representation from the insurance company tells us they can’t tell us how to bill it.

Third scenario, The insurance company pays partially and not everything they said with still some errors.  We have to re-submit.

Forth scenario- They pay nothing and say it is the patient’s responsibility as it goes towards a deductible they had never mentioned before.  Again, a discussion with patient and some discussing and issues for conflict.  The patient is unhappy.

Fifth scenario – They pay nothing and it is the patient’s responsibility.  It was submitted correctly and that is that.  This is where we have to fight for the patient.  The patient also gets involved in this scenario.   We all call back in to verify benefits and discuss with the insurance representative.  Takes many phone calls between insurance company and patient.  It is unpleasant at best.

Sixth scenario – The insurance only pays some and not the full benefit.  The rest of the benefit is written off per “contractual” agreement.  A loss for the business.  The patient is happy.

Etc. scenario--

Final steps:

As you see I could continue with the scenarios as there are so many of them.  I just wanted to give you, the reader the gist of what we all deal with.  The lack of transparency for these insurance benefits.  We just finished a claim that went from a third scenario after 3 years of dealing with it and it finally came down to the fifth scenario, which it becomes the patient’s responsibility when all is said and done.  After three years of dealing with this particular claim, we write a letter to the patient explaining what they need to do, which is fight for their benefit but pay us the final bill.  It is harsh.  It will make the patient mad as they have to pay monies to us and sadly removes the happiness, they felt about getting their hearing better.

HELP!

We need help with this process.  It isn’t good for anyone except the insurance company.  It couldn’t be good for the people working there though. They must hate all the calls and the discussions and the confusion about what is covered and what isn’t.  Medicaid and Medicare are much clearer as it is what it is.

One payor!

Due to this lack of clarity and uncertainty the best case would be to have one insurance for all.  The benefits would be clear and concise.  We wouldn’t need to call to verify as we would know what the hearing health care benefit is as it is what it is.   The patient would be happy, the business would be happy.  There would be less representatives fighting and explaining what the benefits might be.. but they could do something that is more positive and happier.   There would be other jobs for them.  Of course there is always the “supplement” for those who can afford… and then the verifying starts again.   That is a choice though, not the main insurance!

By Kim E. Fishman

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