Lament of a Disillusioned Billing Manager

By D.A.K.

I have worked in home care for almost 10 years now, and I have been a billing manager for over three years. I have learned to become an expert at this stuff. I have seen the good, the bad, and the ugly when it comes to insurance policy and regulations — and plenty of it has been ugly. So when I read about the murder of UnitedHealthcare (UHC) CEO Brian Thompson, I was saddened; however, I was not surprised. 

I have experienced people’s anger and confusion toward their insurance firsthand, and I understand where that anger comes from. I also understand how confusing insurance policies can be: before I started working in billing, I had no idea what a deductible was, or a coinsurance, or HMO, or even Medicare Advantage. This system is so confusing that it seems almost intentionally complex, designed for people to fail to use it; plenty of people online, including in the Tangle comments section, blame insurance companies for people dying due to denial of coverage for health care. Many seem to look at insurance companies as evil and their executives as malignant suits, sitting atop their ivory tower, laughing maniacally at the idea of letting people die for profit. With that caricature of Brian Thompson in mind, it is no surprise that many are supporting the shooter. 

I also believe that the insurance system is an evil in our healthcare system. They put in policies to give themselves an excuse to deny coverage or request their claims payment back. In a few cases, I have seen inexcusable policies that strongly discourage providers from offering certain covered services, such as one insurance plan’s policy, which requires a nurse to be present for each and every home-care physical therapist visit, even if the patient is receiving no nursing care. I will avoid naming the company in case that has changed since it last came across my desk, but suffice it to say that that requirement provided far more cost than benefit.

And, of course, insurers occasionally appear to screw over their members. I have had to give patients, prospective patients, and patients’ families (often a Power of Attorney) the bad news that their insurance will not cover them or will only do so if they foot a large portion of the bill. That can be heartbreaking — many of the people I spoke with were dealing with strife and financial issues, only to suddenly find out that their insurance doesn’t have their back; they must choose between their health or having enough money to live. Many chose to forgo treatment. 

I have also received countless calls from panicked patients or patient families, wanting to know what the bill is going to be if we provide services. When they want me to “make sure,” I carefully reverify their benefits and eligibility with them. I have had at least one patient refuse our services because they once received a large and unexpected bill after receiving a procedure. Despite my assurance they would not receive a bill, they did not want to take the chance and refused treatment. 

For years, I have looked at this health care system, and I have seen its cracks and flaws. These are the major key problems which I have found, will simplify as much as I can:

• Authorization (“auths”). Auths function as permission from the insurance company to provide health care for one of their members. For some services, the health care company must send an auth request with supporting documents, the insurance checks for coverage and “medical necessity,” and after a turnaround time they approve or deny authorization. For many procedures, health care providers must proceed before authorization is approved, and insurance’s determination is made during or after care. If the authorization is denied, it will cause the claim to the insurance to be denied, and so the provider does not receive payment. 

• Medicare. Yes, that federal insurance everyone seems to love. Medicare comes in many “parts,” but I want to focus on Part C, otherwise known as “Medicare Advantage.” The Centers for Medicare & Medicaid Services (CMS) is the federal agency that handles Medicare and Medicaid, and Medicare Part C is a type of plan handled by an insurance company or organization (such as UHC), who are contracted and compensated by CMS. For doing so, those companies can market themselves as offering better coverage and potentially lower costs. Lately, CMS has been increasingly pushing Medicare Advantage insurances to be more skeptical of insurance claims and to use authorizations to determine coverage and medical necessity, as defined by federal law and the Medicare Benefit Manual. CMS has even been encouraging health insurance companies to implement authorization requirements on their Medicare Advantage plans for services that Medicare itself does not require authorization for.

• HMO Plans. If you have ever seen the movie John Q., this might be familiar. HMO plans are marketed as a low-cost, low-premium insurance plan to save you money so long as you follow the rules and restrictions. Patients often face denials or high out-of-pocket costs for seeking care from non-contracted providers, receiving treatment out of state, or opting for higher-cost alternatives when lower-cost options are available (even if they have good reason for doing so). These plans also impose stricter authorization requirements and are more likely to challenge claims compared to other insurance types. 

These are some of the more serious issues within the health care insurance system which I have encountered over the years; but, luckily, I do have some commonsense ideas for how to address them. They certainly would not fix everything, but these are the changes I would make to our healthcare system without having to overhaul the entire thing:

1. Insurance companies are prohibited from restricting coverage to specific states or areas within the U.S. Prohibiting coverage restrictions based on geography ensures that patients maintain access to care even if they relocate.
2. For life-saving measures and life-maintaining palliative care (if the plan covers palliative care), the service must be covered at the same rate whether contracted or not, whether out-of-state or not. If someone crosses state lines to get surgery or sees a noncontracted provider for cancer treatment (etc.), the same rates and costs will apply as if you saw someone who is contracted and in-state. Denial and restriction of coverage for medically necessary life-saving services, for any reason, is prohibited. This would also apply to HMO plans. Guaranteeing coverage for life-saving treatments and palliative care, regardless of network status, protects patients from financial ruin and ensures that emergencies do not result in denials of essential care.
3. Pre-existing conditions must always be covered. 
4. Medical necessity should be determined by the health care provider, not the insurance, without prior authorization. The health care provider has a much, much clearer picture than the insurance company as to if a treatment is medically necessary. Insurers have the right to request justification and audit after services are rendered if they have a reason to believe that service may not be medically necessary, and request money back from the provider should it be determined to not be medically necessary. A clear and explicit reason must be provided by the insurer if they disagree with the provider. The provider has the right to appeal this decision prior to reimbursing the insurance, and appeals must be arbitrated by an unaffiliated third-party . Should the final ruling determine the care not medically necessary, the health care provider is prohibited from charging the patient for reimbursement for services. Should either the insurance or the provider be found to act in bad faith (e.g., arbitrarily claiming services as medically necessary or not necessary, excessive auditing, fraud, etc.), they may be fined and sanctioned by the relevant state-level agencies, including revocation of license to practice/operate within the state in the most extreme cases.

However, I am just a billing manager, discontent with the system. Insurance policies are frustrating, confusing, unfair, and annoyingly complex. People hate insurance companies without understanding how they work, and I can hardly blame them because it took me years to figure it out. However, I want to stress something important: Insurance companies are not out to get you; they do not intentionally let people die to save a buck, and the people who work for them are not evil. Yes, they are  businesses, but from what I have seen they want you to have good health coverage, to protect you, and save your life.

Insurance companies make us providers jump through a lot of hoops and fight to get paid by them, and sometimes they enact policies to intentionally make life difficult for providers, but that’s part of the game — it is business. This is directed at us, your health care providers, not you.

From what I can tell, Brian Thompson was not an evil man. In fact, UHC has been improving a lot over the last couple of years and, if anything, his death is a blow to the company’s reform. 

The flaws in the system are numerous and undeniable, but insurance companies are not evil. I can’t even imagine how many lives they have saved by covering the cost of their health care, but I can say for certain that the number doesn’t even come close to the lives lost due to coverage denials, nor how many people have gotten a surprising bill in the mail. As someone who understands the inner workings of insurance companies better than most, I share the general public’s frustration with them and agree that the system is flawed; but despite its flaws and dysfunction, insurance remains a force of good — and we are fortunate to have it.

D. A. K. is the pseudonym of a Billing Manager for a Rhode Island-based home care agency. He began working in home care in early 2015 and transitioned into billing during the COVID-19 pandemic, applying his experience to improve processes and help patients and the company navigate the complexities of insurance and Medicare compliance.