Business Leadership/Career Advancement

   / Business Leadership/Career Advancement #31  
Every year I go through coverage issues with my plans. Every year. I realize Health Care plans are complex. But when you have the same procedures done year after year, and you have to engage BCBS about why one visit is covered and another is not, there is a serious problem.

I don't trust anything, the minute details always fouls up some higher-up plans.

Insurance pays based on what the clinic codes the procedure as.

We have very complex systems that pays via a matrix on elected benefits and where you are at against a cost share. We don't have the time to micromanage payouts. It's not a human there reviewing each claim...That was the 80's.

99% of the time, billing issues start and end with the way a provider codes a visit. That is where the human part of this lies and most of the mistakes are the results of human interpretation.
 
   / Business Leadership/Career Advancement #32  
Insurance pays based on what the clinic codes the procedure as.

We have very complex systems that pays via a matrix on elected benefits and where you are at against a cost share. We don't have the time to micromanage payouts. It's not a human there reviewing each claim...That was the 80's.

99% of the time, billing issues start and end with the way a provider codes a visit. That is where the human part of this lies and most of the mistakes are the results of human interpretation.
I get that,

Except in my current situation the codes submitted are the same codes submitted prior. Yet "my plan" does not cover the submittal. Why? Well "my plan" is under BCBS, and yet somewhere, somehow the provider is linking into a different BCBS "my plan".

Pretty bizarre. And it takes many people to figure out where or what the provider is submitting to.

The devil is in the details. And you need PEOPLE to review these claims when they go bad. But they should not go bad in the first place. How can "my plan" give me "in network coverage", "apply discounts", not apply "deductible" and not cover any cost of a procedure with the same codes, month to month. It's madness. This has been going on for ....years.
 
   / Business Leadership/Career Advancement #33  
I get that,

Except in my current situation the codes submitted are the same codes submitted prior. Yet "my plan" does not cover the submittal. Why? Well "my plan" is under BCBS, and yet somewhere, somehow the provider is linking into a different BCBS "my plan".

Pretty bizarre. And it takes many people to figure out where or what the provider is submitting to.

The devil is in the details. And you need PEOPLE to review these claims when they go bad. But they should not go bad in the first place. How can "my plan" give me "in network coverage", "apply discounts", not apply "deductible" and not cover any cost of a procedure with the same codes, month to month. It's madness. This has been going on for ....years.

I'll give you a example with my own mother.

She had to have carpel tunnel surgery. I told her to go to a specific doctor because she was good and she took her insurance. She did multiple visits in preparation for the surgery. All visits were paid as in network...all was well.

She goes and gets the surgery and we expected to pay the rest of the cost share because she didn't meet the out of pocket yet. We get the bill showing the provider was out of network and she had to pay the amount above and beyond the reasonably and customary amount her insurance paid. The doctor decided to leave the network for a month, didn't tell any of her patients, and proceeded to balance bill everyone during that month. No explanation given.

I was pissed. They had no idea who they just pissed off. It wasn't the cost I was mad about, it was the gaming of the system by the provider.

I got my attorney and we went down to the insurance department. I deal with the insurance department all the time and know them well. I showed them what this Dr. and her office did. They got a lot of complaints from this one place. They sent a letter to this provider but they didn't acknowledge it.

My attorney sent a letter and laid out the facts. This doctor and her office manager got obstinate and tried to blow us off. We brought suit and when we won, the judge ordered all services for others that got caught up in her ordeal to refund back to the in network amount.

To make a long story short, this issue of her office manager trying to up the revenue for a month cost this doctor her practice here. She now lives in another state practicing medicine, with hopefully a smarter office manager.

Moral of the story is...99% of the issues with insurance can be tracked back to the provider. Insurance pays based off a computer derived matrix that takes the human mind out of the equation. This is by design.
 
   / Business Leadership/Career Advancement #34  
In my last ten years of working life, the thing I most dreaded was what I've termed, "The Curse of Competence." Its now called lots of other things like, "Task Creep," or "Performance Laddering."

All of these, will eventually lead to people just giving up any direct relationship with a company that has bad management habits.

These are all slightly different though.

Performance Laddering is where management just keeps upping, little by little, performance goals till everyone is burned out, and the system has already reached its maximum with the resources provided. So no more bonuses, even if you stay at a prior achieved level of productivity. This makes every one resentful towards the company.

Task Creep, is where lots of things, not in your job description get added, little by little, till you are doing damn near every task the company does. Its not that you are working harder, its the confusion of task switching that burns people out.

My worst experiences were with, "The Curse of Competence." Everything you've done you've done well, with out complaint and on time. .... or at least better than others have attempted. You get assigned all the more difficult tasks. And eventually you only get assigned all the hardest, most intractable and previously messed up tasks. Then everyday, is a day of Crisis that NEEDS to be solved RIGHT NOW.


That's when I quit, and arranged to work with my last company as a consultant. :)
Oh, I remembered I had this too, I was also afraid of it.
 
   / Business Leadership/Career Advancement #35  
Moral of the story is...99% of the issues with insurance can be tracked back to the provider. Insurance pays based off a computer derived matrix that takes the human mind out of the equation. This is by design.

My BS meter is screaming.

Family PT practices, extremely diligent billing practices and insurances screw up on the regular.

BCBS is about the best there is to work with and probably the least of the troubles (but still not great)

Medicaid, Medicare, Aetna, United Health Care, Cigna, Humana, and the nobodies of the industry suck.

We have done billing in house and billing by 3rd party, what we have found is 3rd parties are willing to write off our money far too easily and process most billing in house now.

Hold times are ridiculous, we have cheat sheets for every company to talk to a human. Pay folks literally to sit on hold with insurance companies all day. Our recovery rate is well over 90% each year, far better than the average. But it requires making up for insurance shortcomings.

We are not associated with a hospital system.
 
   / Business Leadership/Career Advancement #36  
I have had 2 very similar BCBS situations lately.
Provider errs in billing.
I try to help, even send in bills myself.
After 90 days, BCBS claims they do not have to pay in network, and claim I am off the hook.

So, I'm left with an insurance letter that says I don't have to pay a provider (that they didn't pay either).

Now, I'm very concerned that 5 years from now Kurshner's family buys the debt, and the judge laughs that I should know a 3rd party (BCBS) cannot discharge someone's debt.
 
   / Business Leadership/Career Advancement #37  
I have had 2 very similar BCBS situations lately.
Provider errs in billing.
I try to help, even send in bills myself.
After 90 days, BCBS claims they do not have to pay in network, and claim I am off the hook.

So, I'm left with an insurance letter that says I don't have to pay a provider (that they didn't pay either).
To achieve your goals and become a leader in your field, you need to constantly learn and develop. One of the key success factors is the willingness to take responsibility and make difficult decisions. I also made a table about career plan, I also found the importance of career planning essay for this. Maybe that gave me something too. In addition, you must be able to communicate, convince and inspire your colleagues. If you are aiming for career growth, then it is important to choose the right path and learn how to work in a team. Success is in front of you, the main thing is to know how to use it!
Now, I'm very concerned that 5 years from now Kurshner's family buys the debt, and the judge laughs that I should know a 3rd party (BCBS) cannot discharge someone's debt.
interesting
 
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