We are on a first-name basis with someone in our community named Tina.
Let's call her poor Tina. She works in an oral surgeon's office in our community. She handles insurance, contentious claims and other things that mere mortals can't comprehend.
We have been sharing regular conversations with Tina over payment for service that our oldest daughter received nearly a year ago. As we come up on the 12-month anniversary date, that $2,000-plus bill hasn't been settled yet. The office is still awaiting payment from the insurer.
I won't identify the insurer except to say it's a big one. I will say that, as much as we like Tina and many of the fine employees of the insurer, we're tired of talking to them. And frustrated. And getting worried.
I'm eventually going to circle back to consumer-directed healthcare, so bear with me.
As parents of the patient, we pre-emptively tried to do everything "right." We got pre-authorizations. We got letters of coverage. We got waivers to go to a local provider. Now, we're getting a tour of the maze of post-coverage settlement.
We've had checks sent to the provider for the wrong amount, checks returned, red flags put on our claim to try and move it along, faxes back and forth, and now we're getting calls suggesting that we pay a little bit each month – you know, in case the insurer doesn't settle any time soon.
Excuse me, but didn't we jump through all those hoops ahead of time to avoid this scenario?
Many of you – probably all of you – are chuckling, nodding or otherwise sympathizing. "Welcome to the world of healthcare, Mr. Bazzoli," you chortle.
Of course, every consumer in America knows that this is the current state of claims adjudication between providers and payers. These two long-time adversaries are duking it out, with the consumer caught in the middle.
This is precisely why consumers will not flock to health savings accounts, consumer-directed healthcare plans and other such inventions that put consumers at more risk for the cost of their healthcare. People will take on risk if there's a promise of reward for them. I'm not sure many will feel confident enough in the system to take on more financial risk for their healthcare.
Consumers feel that healthcare costs are shrouded in secrecy and not at all transparent. How does that enable comparison shopping? When I recently had my car serviced, I was assessed $48 for having an air filter replaced. Next time I'll opt to do my own "outpatient procedure" with a $14 replacement filter from a local auto supply store. Options aren't nearly that simple in healthcare, for sure, but they need to be at least clear.
But it's the inability to adjudicate claims that may be the showstopper for consumers. Who will want to take on more risk and willingly be the arbiter between provider and payer when the stakes are even higher?
It will be interesting to see the response to the higher health savings account limits and other changes approved by Congress at the end of the 109th session. In theory, improving the HSA approach may be an important step in reforming the nation's healthcare system.
But consumers have many questions that need to be answered before they take on more risk. Claims adjudication and price transparency are big issues, and there may be others.
Providers are probably shaking in their boots, too, since it's so much fun to get patients to pay days, weeks or months after services are provided.
Just ask Tina. She's probably getting a little tired of talking to us, too.