This will be long but its worth it and has a happy ending. Also please excuse any grammatical errors. English is my first language but I suck at grammar and have had a few beers. 🙂
Years ago I worked in a call center for one of the bigger health insurance companies and one of the benefits for the plans we offered was oral surgery. So this story involves health insurance claims billed from a dentists office.
One day I take a call from woman in tears saying her dentists office is charging her thousands for multiple wisdom tooth surgeries for her teenagers because we haven’t paid the claims and wants to know what is going on. After some digging I find that this isn’t the first call we received regarding this situation. Both the member and the provider (dentists office) has called us multiple times on this issue and coworker I am close with took an earlier call regarding this issue.
The problem was that the dentists office was submitting the claims with the member SSN instead of policy ID number, which was causing issues with the claims getting to the correct claims department for processing. This insurance company had one main mail processing center for the entire country/thousands of different policies. Without the ID number it can be almost impossible to know which office needs to process the claim as they can have different computer systems to process the claims.
Said provider was told on 4 different occasions to submit the claims with the ID number instead of the SSN to have these processed. A really simple correction which they never made. We are talking 4 different claims where they would have had to replace the SSN with the ID number, nothing crazy. When my friend took the call the providers office demanded a self addressed stamped envelope to send these into for reimbursement. They received said envelope, sent in the claims using the SSN, and waited.
This is where I come in. 2 months later I receive a call from the wife of the policy holder saying the doctors office is threatening to send them to collections due to not receiving payment from us. This is where an important tidbit comes in to play. They were a “preferred provider” and by law could not charge the member because claims must be submitted/processed by us before they can charge the patient. This is part of the dentists office contract with us.
So I put the member on hold and call the provider. This is where the fun starts. The office manager starts going off on me saying she submitted the claims in a self addressed stamped envelope that she sent to us and still didn’t receive payment. So I put her on hold and have 3 managers looking for this damned envelope. While they are still looking for it I get back with her and reiterate she is a preferred provider, the claims have not been submitted with the ID number, and that until we find the claims she cannot legally bill the member. That is met with a “Fuck you and fuck your insurance company, I will do what I want” and after that she hung up.
So being the good call center employee I am I immediately call the office back and a guy answers. I say “I am RedShirtDecoy from X insurance company I was just speaking with Mrs. Office Manager and I believe we were accidentally disconnected” in the sweetest voice I could muster. The poor guy comes back after 30 seconds and says “she refuses to talk to you”. I inform the nice gentleman on the phone that if this isn’t resolved then I would be forced to contact provider relations. He repeats what I said to someone and returns with “she says she doesn’t care and she refuses to speak with you”. I say I understand and say I have to report this to provider relations. For what its worth provider relations is who approves preferred providers and handles the contracts with them. I also have to say his was a MAJOR health insurance company. If the office looses their preferred status they could lose up to 35% of their customers due to having our insurance. Think Humana, Anthem Blue Cross Blue Shield, United Health Care, ect.
I go back to the member, assure her that legally she is protected and if they send her to collections she should call back so she could be connected to our legal department. I also inform her that I would be reporting this to provider relations. Later that day one of the managers finds the envelope of claims forms. The reason we couldn’t find it initially? It was addressed to a specific supervisor (based on the call my coworker took before me) and the mail team just set it on his desk full of paperwork overnight and he never saw it until they were looking for it.
Monday morning comes around and its time for a follow up. Claims adjusters are diligently working on processing all the claims and issues payment via check to the provider for the amount they were expecting. I call the member to let her know and she was super relieved. Then I call the provider…
A different guy answers and I explain the situation to him, including that provider relations could be involved. Turns out he is the dentist who owns the practice and the woman who cussed at me was not only the office manager but his WIFE. He says “what is your direct line, she WILL be calling you later today”. 3 hours later I get a call to my direct line. It is the office manager who cussed at me. She apologizes to me for her behavior and seems happy that a check is on its way.
Seems like the end, right? Wrong!
Over a month later I get a frantic voice mail from the same member who had my direct line. At this point her husband is out of the country for work, she is trying to move herself and family across the country for his upcoming transfer to a different office, and she gets a call from the office manager saying they received the checks but wont accept them. The office manager told her they have to charge her for the full $7k price and will send them to collections in 2 weeks if payment isn’t received. Why? Because they dont trust we wont adjust the claims to pay less and demand money back from them. That’s not how any of this works because of contracted amounts for services but whatever.
I reassure the woman that she is still protected due to the office being an in network provider and if they send her to collections that we could get our legal team involved. I put her on hold again to call the office again.
The office manager demands we have a supervisor review the claims to verify we wont take any money back. The reason she demanded this? If a claim is audited and found to have paid to much we will issue a “refund” on the claim where they have to pay us back. I know this sounds shady but in reality this only happens if the claim was issued with an incorrect diagnosis code/procedure code combo that pays more than the correct diagnosis code/procedure code. Think a claim that was submitted for a complicated tooth extraction but a random audit/review of medical records found it was a simple tooth extraction that should have paid less.
We do that, send confirmation to the doctors office, the doctors office is now happy and so is the member. I get a call back from the office manager who apologizes once again and seems to be happy at this point. The office got their money, the member didn’t have to pay out of pocket, and everyone is happy in the end.
Two weeks later I come into work and see an envelope on my desk. It’s a check for $150 from the company I work for with a hand written letter from the VP of customer service saying something along the lines of “thank you for going above and beyond”.
Turns out the member I had helped called in and asked for my supervisor once everything was resolved. Only she wasn’t happy talking to just my manager, she was adamant about talking to my managers supervisor, then that supervisors supervisor until she reached the VP of customer service. She then told him about what I did and how it was resolved without her having to pay any extra money.
So in the end I was able to help a woman who was super stressed and over her head, I received not one but two apologies from the office manager of a dentists office, and ended up with an extra $150 in the process.
Working in a call center can be soul sucking but that situation was incredibly satisfying/worth it.
submitted by /u/RedShirtDecoy