Monday, September 23, 2013

Questions that should not be hard for a health insurance plan to answer

Is a lab in-network for my insurance plan?

CIGNA's answer: Maybe. There's no way to know for sure, unless you use Quest. See what happens. Depends on who decides to bill under which provider number. Answers from the lab or from CIGNA in advance do not correlate to how the claim is processed. No way to obtain a definitive answer that you can then rely on.

If a lab is in-network, should the insurance plan cover the out-of-network pathologist claim tied to that lab as if the pathologist were in-network?

CIGNA's answer: No. Yes. Maybe. No written policy.

If a lab is not in-network, should a claim be paid as in-network if an in-network doctor chose them?

CIGNA's answer: No. Tough luck, you should always check on which lab your doctor is using for every test, even though we offer no definitive answers on whether any given lab is actually in-network. But no written policy saying this.

If a lab is not in-network, should a claim be paid as in-network if nobody in-network can provide the same test?

CIGNA's answer: No. Yes. Maybe. Could fall under medical necessity, but that would probably require an appeal and massive cooperation from your doctors.

If a lab is not in-network, how can the insurance company say that the lab failed to follow insurer guidelines and therefore the patient owes nothing to the lab?

CIGNA's answer: Um, well, that's what the EOB says, but we might change that later, and there is no way to guarantee finality.

If a lab is not in-network, how can the insurance company apply a discount to the amount that we owe the lab?

CIGNA's answer: No answer.

Does a payment to an out-of-network provider cross-accumulate toward the in-network individual deductible? Toward the in-network family deductible? Toward the in-network individual out-of-pocket maximum? Toward the in-network family out-of-pocket maximum?

CIGNA's answer: Yes to all of these. But not until the out-of-network claim is actually processed, even if that takes much longer than any other claims. And we won't give this information in writing.

If the order of claims affects how much the patient owes, should claims be processed in order of date of service? In order of date of claims submission? In whatever order most benefits the patient? In whatever order most benefits the insurer?

CIGNA's answer: In order of date of claims submission, subject to a lot of random variation, with hints of an internal policy of rigging the processing order to benefit CIGNA. No written policy, not even an internal written policy answering this question.

If claims are processed in the wrong order, how can that be corrected? Can $1000 that the insurer wrongly told the patient to pay to 20 different providers be reimbursed by the insurer directly to the patient, since the providers have already been paid? If the insurer now sends payments to 20 different providers that duplicate payments that the insurer already told the patient to pay, can we get a list of those payments? Can amounts that the HRA wrongly paid on the patient’s behalf be reimbursed directly to the patient? Restored to the HRA?

CIGNA's answer: Claims are always processed in the correct order. Mistakes cannot happen. You can always appeal, but you cannot reference any written policy about how claims should be processed. Duplicate payments to in-network providers can only be sent by CIGNA to the providers, with no tracking of those payments available to the customer. If an amount was wrongly paid by the HRA, the customer must convince the provider to refund the HRA payment to CIGNA, who will then theoretically put the money back into the HRA account, where the customer can then submit manual requests for the HRA to send payments to other providers. So if CIGNA told the HRA to pay Doctor A and told the customer to pay Doctor B, and then CIGNA later decides to pay Doctor A themselves, the customer must convince Doctor A to refund the HRA payment to CIGNA, wait for CIGNA to put it back into the HRA, then ask CIGNA to pay Doctor B with the HRA funds, wait for that payment to go through, and then convince Doctor B to refund the customer's original payment to Doctor B. Because what could go wrong?

The above questions are really about how the health insurance plan should work. Then there’s the parallel questions of how it will work, since practice and theory differ. It seems like somebody should be able and willing to provide authoritative answers to at least some of those questions, in a way which we can then insist that the insurer abide by those answers. But, well, no.

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