I really hate our whole healthcare/insurance system, which is why I get excited when I hear about reform and discouraged when it seems to go off-track.
This is on my mind today because of the inane interaction I just had with my health insurance provider, Humana.
Back in June, when we were traveling, our daughter got an infected toe, so we went to the nearest convenient place, a “doc in a box” in Bloomington, Indiana.
We paid $25 upfront as a co-pay, and they said they’d bill Humana for the rest.
Humana did not pay, so I got a statement from the doc-box. Total charge: $109.00. Less our $25.00 payment, that’s $84.00 I owe them. A helpful note was included: “Your insurance was filed but did not pay. Your insurance was refiled today. If you have questions contact you insurance. Please pay balance due.” A further note in case you didn’t get the full import: “Your insurance is filed as as a courtesy. If you have insurance questions, PLEASE CONTACT YOUR INSURANCE CARRIER FIRST, then advise us of your claim.”
I got on Humana’s website. I was able to remember my username and password for a change. I accessed the Claim Details. “Status: COMPLETED.” OK, but was it paid? “Paid: 06/23/2009″ Aha, so it was paid? “Humana Paid: 0.00″ Oh, I guess it wasn’t paid.
Then I noticed this little message, which I will reproduce in its entirety.
Message 1: This service was performed by a non participating provider and exceeds the Maximum Allowable Fee (MAF). You are not responsible for the difference between the MAF and the amount the provider bills you for the services.Should you be billed for this, please contact 1-866-427-7478. For additional information please refer to the Schedule of Benefits and Glossary section in your Benefit Plan Documen
The Maximum Allowable Fee, in case you’re wondering, is $91.07. Don’t ask me how they derived that arcane number, but there it is. Apparently I am not responsible for the difference between the MAF and the total charge. That difference is $17.93, and if I’m billed for this, I should call Humana at the number listed.
So I did call. I asked my first question. Why is there a listing for the date the claim was paid, when in fact the claim was not paid? Do you see how that could be confusing? No, the rep maintained, she did not. Well, I said, belaboring the point most egregiously, when a normal human being hears that zero dollars were paid on a certain date, most people would conclude that no payment occurred on any date. So how could Humana list a date for the payment, when there was no payment greater than zero? She confessed she could see how it might be confusing to me, but it was not confusing to her.
Once we got that foolishness out of the way, I asked about the MAF. What’s this $17.93 for which I am “not responsible”? That stumped her, and she had to put me on hold for half an hour, after which time she came back, apologized, and said someone would have to call me back.
I proceeded to bend her ear for a little while longer about Humana’s online database of participating physicians. We’re supposed to use this to find a doctor. But the information is vastly out of date, with most of the physicians in my area flooded out after Katrina. That was four years ago, by the way.
A short while after our friendly chat ended, I got a call back from Humana. The rep explained there is a typo on the website. The text that says “You are not responsible” should read “You are responsible.” Ah, what a difference one little word makes.
Oh, by the way, this medical expense would have been covered if we had just taken the time to call in to Humana and ask for a referral to a participating physician. Never mind that we were on the road and just wanted to get our girl to the nearest convenient doctor. The doctor we chose was not “participating” so we’re not covered.
What part of this system makes any sense?