They spent hundreds to almost avoid paying eleven hundred

by Michael S. Kaplan, published on 2011/04/26 07:01 -04:00, original URI: http://blogs.msdn.com/b/michkap/archive/2011/04/26/10158127.aspx


If my Adventures in Insurance annoy you. then you can skip this blog....

Regular readers may remember something of my insurance travails in getting my iBot battery replaced.

If not, you can go to Why not engineer inefficiency?, aka "Forget to charge my battery and take me to Jabba now" the iBot said to see the whole story about how Premera Blue Cross paid only $24.09 on a battery that costs $1100.00.

Basically, they billed it with the code 2008 HCPCS K0108 (the text description for this code is "Wheelchair component or accessory, not otherwise specified"). This sounds like maybe they replaced the cigarette lighter if it had one or the valve stem cover on one of the tires.

Note to Blue Cross: if you are billed $24.09 for the valve stem cover they are bilking you.

But I was not bilking here.

Finally, after claiming they weren't receiving all the right paperwork many times (at this piont several copies of my appeal are floating around over there; one day they may double or triple pay me if they keep track of the money as closely as they keep track of the appeal paperwork -- note that I will give them their money back since I'm not a thief.

Anyway, here is the letter (click on it to see it bigger if you want):

insurance appeal approved!

Text in case you can't see the letter above:

This letter is to inform you of the outcome of the appeal you submitted requesting additional reimbursement for the wheelchair batteries you received on August 17, 2010 from Depuy Orthopaedics Incorporated. After a comprehensive review of the appeal, Premera has concluded that the wheelchair batteries are eligible for additional payment under the Plan. The reasons for the approval of your appeal are explained below.

Appeal Process

To evaluate this appeal, Premera included the participation of a Medical Services Administrator (MSA). The MSA reviewed your letter of appeal, all relevant information, and the terms and exclusions of the Microsoft Live Well Premera plan.

Reasons for Approval of Appeal

The Microsoft Live Well Premera plan allows benefits for charges to repair or replace covered items when worn out by normal use. The reviewer concluded that the description of this particular item is not comparable to any durable medical equipment or supply item procedure code description currently in place that has an established allowable charge. Based on this information the reviewer determined it is appropriate to allow the wheelchair batteries you received from Depuy Orthopaedics Incorporated replacement at the billed charge.

We are having the claim for the wheelchair batteries received on August 17, 2010, reprocessed to reflect the outcome of this appeal review. Benefit coverage is subject to eligibility, the terms of the Microsoft LiveWell Premera plan benefits and all contractual limitations and provisions.

Note that they have not paid yet: they will now process it, and hopefully cut me a check at some point.

Since the batteries were received last August 17th and I paid for them about a week before that, we are on track to see me get paid at the one year anniversary.

Of course Blue Cross has had use of the $1100 for that whole time but I will receive no interest or allowance for inflation for this loan that I have given them while they bumbled paperwork.

I suppose I should say thank you to the thievery.

Now I did happen to call them to ask whose job it should be to request that a code be added -- I mean, given the problem here doesn't that make sense?

I was told that it would not be Blue Cross; they are merely denying the submitted code and it would be the people who want to be paid who would do that.

But I'm the one who wants to be paid! Do I have a way to get a code added?

Apparently I do not. Only a provider of services or equipment can do that.

Of course in this case the provider doesn't really do that sort of thing because they are closing up shop in a few years and the billing insurance is just a convenience thing: they make me pay upfront for everything.

So they have their money.

Of course eventually I will need a new battery again.

At the rate they are going, I'll be ready for a new one soon after they pay for the old one!

Then Premera Blue Cross will just have to go through the same rigmarole again.

The form to submit a claim has no space for "special appeal claim # for the last time the very same claim was paid off" which means another appeal, hopefully a little faster next time.

I think the purpose here is to get people so pissed that they just give up. They'll spend hundreds (if you consider the hourly of all the at least 9 people who've had to deal with this over the last 2/3 of a year) to avoid paying me $1000.

And we wonder why insurance doesn't keep pace with inflation?

You know, I could start my own insurance company too. It's just that I'd hate having to feel so unclean every time I'd have to pull this kind of crap that I'd have to be showering 12 times a day. My skin would chafe too much and it just wouldn't work.

I should feel grateful, but really I would like my employer to consider the fact that one of the reasons insurance costs surge is they paid for all of this non-streamlined stuff. You don't think it will be reflected in their rates.

I don't even get it - they pay for the serviecs stuff with minimal probing, and then nickel and dime the device stuff? Geez.

Microsoft could probably hire a nice gaggle of insurance administrator types whose full time job is to intelligently process all of this. They could "self-process" their self-insure, and it would be cheaper than the overhead of what they do now. All they needis a group that they control the charter of....


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