I have worked in the mental health field for about 13 years. Initially, I was a Social Worker. That’s what I ended up majoring in when I was in college and I did enjoy the work I did. But, once I got pregnant with I., I tried to carve out a niche for myself so that I could work but still be with the children….not easy when your job usually consists of working with people!
Life took me in a nice direction and I ended evolving into basically a liaison between local therapists and the insurance companies.
I was able to work at home mostly, and stay with my boys – it was priceless and couldn’t have happened at a better time. Fast forward to today, and I still do a bit of claims work for 2 New Mexico therapists. They’re fabulous women and when I moved away they still wanted me to do their claims for them – so I still had some work while we were setting up….did I say these women were just totally awesome!!
While all this has brought me many blessings, the reality is, there shouldn’t be a job for someone like me. Insurance claims should be processed so simply and easily that providers wouldn’t need to chase down payments…or pay someone like me to do it.
Doing this work has really opened my eyes to how broken our health insurance system is. It needs to become much more efficient and streamlined, and if that happened, it’s my estimation that enough money would be saved to provide health insurance to many more individuals, if not all US citizens.
All that I’ve seen and dealt with has made me want to do something about it. Now, as a working mamma of 3 young kids, there’s not much I have time to do anything about anything, but, I can expose a bit of this BS by writing about some of the stories here.
I can’t use the names of the clients of course, but, I can tell you lots of other details that will just blow your mind!
Lets start our “tales” with the one that pushed me to actually write some of this down…because it frustrated me so much, and has been going on in some form or another for soooo long (over a year!).
The one therapist I work for started seeing a young woman with disabilities. In our country, many adult individuals with disabilities are provided with both Medicare and Medicaid. This is very helpful for the client, and it should be helpful for the provider, but come to find out, it’s actually quite the opposite.
When we first began seeing this client, we weren’t credentialed with Medicare, only Medicaid. So, we submitted claims only to Medicaid – who was to pay because we weren’t credentialed. In October 2008 Value Options, then the entity that held the Medicaid contract for mental health services in New Mexico, decided that this would no longer fly. We’d have to submit claims to Medicare to get a letter of denial and then submit the claim to them.
Fine. We’d had to deal with that before with clients who have 2 types of insurance coverage, not with Medicare and Medicaid, but still, it wasn’t a surprise. So, I submitted the claims to Medicare as instructed. But, Medicare never responded. I tried to call, but, to my surprise, Medicare doesn’t take calls about specific claim issues, unless you’re a provider! So, I’m stuck. No response on my claims, and no way to contact anyone.
I must have resubmitted these claims at least 4 times each time trying to talk to customer service who, each time, gives me a different answer as to why these claims haven’t been processed. Finally I get someone who gives me the answer…..your claims haven’t been processed because you aren’t a provider. Medicare doesn’t even look at claims unless they’re submitted by a credentialed provider, which we were not.
Remember now, all this time, 4-5 months has gone by, and the therapist wasn’t paid for these claims (6-8 sessions a month).
Armed with this new information, we started the process of becoming a provider with Medicare, all the while trying to get Medicaid to pay the claims.
Finally, we were credentialed with Medicare, and at this point we also have the Medicaid Assistance Division (the state watchdog) who tried to help, but, our problem was low on their totem pole and they were slow getting things done.
In the end, the squeaky wheel got the grease and all the claims were paid…..almost exactly 1 YEAR later!!!
The therapist and I were so happy we were done…but, we spoke too soon.
During this whole…thing, the Medicaid contract in the state of New Mexico changed hands to a company called Optum Health; a division of United Behavioral Health. At first, they paid the claims no problem. Then in Aug of 2009 they just didn’t pay – they didn’t deny, but they didn’t pay.
I called in and was told that according to Optum, this client had another level of coverage that should kick in before them. So that actually makes for 3 types of insurance…..and no one wants to pay!
So, I call Evercare, the “other” insurance. They said that although they do see the client as covered, they don’t pay for mental health services in New Mexico because Optum has the mental health portion of the contract for the state. Shouldn’t Optum know this?
So, I call Optum back, sort it all out and a few weeks later they pay one of the two outstanding months gets paid. I wait a bit longer, and still nothing, so recently I called again and asked what was going on. If you can believe this, I was told that Evercare should pay….by the same woman that helped me before!!!!!
So now today after I’ve had to re-expain everything, she tells me that someone from Evercare should call me and help me sort this all out because Evercare does pay some mental health claims. WTF????
I’m not sure how this will turn out. I’m in the waiting stages right now and will keep you posted on how this resolves itself….if it ever does!
It’s situations like this though that waste time and money that could be better spent on treating clients, and, lowering the cost of insurance!
Unfortunately, I’ve got tons of stories like this after nearly 9 years of claims work! This is probably the longest running, but, as you can see the system is not run in the most efficient way (and that’s just one problem!).
In this example alone, the government (who remember, is behind all of these benefits in this story – the client has all public run types of insurance) would save a bundle! If they just administered these benefits as one company for everything, imagine the overhead they’d (and we’d!) save. Not to mention the ease with which all of this would have been taken care of with….oops, actually IT NEVER WOULD HAVE HAPPENED!!!!!
There would be no situation in which someone had several different types of coverage from several different companies; all of whom have a stake in NOT paying claims. There would be one place you would send claims to – one payor.
As someone who works on the inside of the system, with quite a unique vantage point I might add, it is quite sikening what goes on in the name of keeping us “healthy”!