You wanna know why calling your health insurance is absolute dog shit?
I'm tracked on so many different metrics for handle time. Those metrics are then used to distribute raises and bonuses. The a few of them are handle time, correct information given, time spent adhering to a schedule, extended break time, along other things.
Handle time, this incentivizes is to finish the call quickly. Not to give accurate information, but just to finish the call quickly. The benchmark they have to be a 3, which is meeting performance on a scale of 5, is about 7 minutes or so. Very few people actually fall above that.
Correct information given, I used to be audited once a week. A dedicated employee would pull one call a week to review. Last month I took 1025 calls. That's not counting providers who had multiple patients, just the amount of calls I had. We no longer audit once a week. Now it is once a month, and it is a lottery system. That means I may not be auditted for months at a time. And this would be done by a manager, not a dedicated employee who has not taken a phone call in years. We get updates on standards and procedures every month that they do not have to pay attention to.
The other metrics used are largely just to track us and make sure we're “approaching customer satisfaction”.
These are for contracted employees only though. The workers who you call and it's on the Philippines or elsewhere? They can give you all the wrong information and they get no push back. There's no accountability, there's no guidelines to follow. This is directly from employees 3 or 4 rungs up from me. Sometimes half my day is correcting information given by those representatives who are held to no standard.
Not only does your insurance contract out information, but your doctors do too. It's not uncommon, that there are three calls for a service you're getting. One from the actual doctors office, one outsource that is onshore, and one outsource that is offshore. The information that they get is often your medical history, social security, address, phone numbers, and other identifying information that probably shouldn't be floated around to different companies. HIPPA violations? What's that!
Here's some other fun things your insurance does!
If your provider calls in to dispute a denial we gave, we cannot advise for the provider to appeal the decision. As a member, at least in the States I service, you're given 3 different appeals and what's called a peer to peer. We extra extra extra CAN NOT advise your doctor to do the peer 2 peer, even though this would be the best way to appeal.
The people who work in authorizations and the appeals do not have any medical training whatsoever and they work with less systems that I do. Everything that gets denied is by someone who knows nothing about medical services, it's just a random Joe like you.
We change the rules for things constantly and do not let any providers know and don't make that information easily available. They do not say this explicitly but most of the time when something is denied, we send out a generic letter with the wrong department to call anyways.
Did you know how increasingly frustrating the automated systems have become? Sometimes providers are on hold for hours because they go to the wrong department because the automated systems don't get them to the department they need. And since there's no communication between departments, we are unable to provide all the right info or even the correct department to go to. The automated system also determines if your provider needs to speak to a representative or not.
Did you know that even if we approved an authorization, we can deny the claim? On every precert we send out there's a phrase that says “Authorization is not a guarantee of payment”. This means your provider can call in to authorize a service, the precert department will not check the benefits and just approve or deny based on the medical policy. The people who we've already established have no medical training at all. So they can approve something not covered by your plan at all, and then the service will deny even though the provider got the go ahead to perform it. I've seen personally, we will approve a bariatric surgery for a non covered diagnosis, many many many times. And there's no recourse to get it covered because of that simple phrase “Authorization is not a guarantee of payment”. Great right?
It is 2023 and your health insurance is only now being dragged into the 21st century. Your doctor is told that in order to appeal, they have to mail in the appeal. A fax is available, but under no circumstances am I able to suggest that. Why? Because! That's why.
Did you know a lot of claims deny based on an internal program? This program comes through thousands upon thousands of claims and denied them automatically. This system certainly never makes mistakes, and never causes headaches for everyone involved.
If your policy is in one state and you receive care in another state, let's hope the claim processes correctly! If not , your doctor calls in to the state in which the service was rendered. Then we use a proprietary system to communicate with the other states insurance. We advise to wait 15 to 30 days for a response. We do this instead of calling them directly. We can't give you any information on what's actually going on either, because we don't really know.
This is by and large just a small segment of what headaches health insurance causes. If I had my way, the whole system would be burnt to the ground and health insurance executives would be tried in the Hague.