The letter was from Phillip’s health insurer. (H-m-m-m, no unmarked envelope THIS time!)
It stated his daughter’s emergency surgery for “acute cholecystitis” was NOT medically necessary.
W-H-A-T? Isn’t this (one reason, at least) why we have health insurance?
Phillip’s reaction? Classic. Called me. (That’s fine.) Blamed the insurance company; “my experience is they reject all claims as part of protocol.” (Sad consumers have that point of view.)
The problem; gall bladder surgeries are more often than not done on an outpatient basis.
I urged Phillip to find out if the claim sent to the insurer accurately reflected the fact his daughter’s gallbladder was about to burst! Let the hospital know you’re taking notes; i.e., date, time, who you’re talking to and next steps. Calls like this are often recorded. Remind
them of this. Key is to establish (shift) accountability!
Hospital is reprocessing the claim. Apparently the proper codes may not have been used.
Sounds like a fix. (JINX)
To my insurer friends, here’s a Tip within a Tip.
Send that cold and alarming letter to the provider. As Phillip learned, they’re more than eager to get paid.
Bonus. Your members will have one less reason to dislike you.
