You have been there. A mistakes is made, but a solution cannot be found.
My first inkling that I might be a victim of an incurable mistake is an invoice for lab tests. I look at the bill and see my insurance company paid .02 cents and I owe $97.10. This was a mistake, as I had kept careful track of my deductible – and I had fully met my $1200.00 deductible the month before these lab tests.
Round 1 (next morning) I call and hit the jackpot with a representative who looks through the file, finds the error, and then documents it for the “researcher” who will get it first. Then it goes back to claims and the bill will be resubmitted for payment. I am on the phone about 30 minutes and am thinking … wasn’t that easy. How refreshing!
Round 2 (2 weeks later) My resubmission of the claim is denied for the same “WRONG” reason the first one was — my out of pocket costs were miscalculated. My first representative saw this and documented it, but somehow whoever the researcher was missed it. So I email them. I get a response I cannot open at first (security issues) and when I do, it restated their position about the out of pocket and flatly denies the claim.
Round 3 (next day) I call and find out that they admit a mistake was indeed made, but it’s really too hard to fix and there is no provision for fixing it. WHAT? This particular “incurable mistake” happened with a pharmacy error in May of the previous year. It cannot be fixed because pharmacy (prescription medicine) has only a 15 day window in which anyone can challenge a pharmacy error.
Yes, that’s right…. this mistake – that’s not visible on my account online at all, was made ten months ago, but I missed the cut off time (15 days) to fix this. How could I even know there was a mistake till after my deductible was met and my claim was denied? I would never have had any idea the “deductible calculator” of their system was malfunctioning.
They cannot fix it at the source, and they suggest refunding the pharmacy that gave me the meds and have them refund the money, less a copayment to me. Or basically making this a “new” claim. WHAT? First, I paid the entire amount towards my deductible, not “minus a copayment”. They can’t give it all back because I haven’t made my out of pocket limit for the year, only my deductible. Bit of a catch 22, but that’s crazy. How am I going to get a pharmacy, Wal-Mart in this case to give me back that money?
At this point if you are getting confused, so was I. What has Wal-Mart got to do with this? The insurance company made the mistake…. Why not just fix it? There has got to be “someone” who can go into that system and put the $$ that I paid right back in the place I paid them (May 2010). Then their computer system will match with the correct information in my account and they should pay ALL of my lab bill. That’s the way it should work — but likely it won’t.
It makes me think, do they keep 2 sets of books? — why doesn’t my account (that I can see online) match what they have on their side? And if it doesn’t and they know now it’s their error, why can’t they fix it? Someone has to be able to fix it! They are providing false information to me, or keeping false information in their accounting system or potentially both. How many others has this happened to? Where one small mistake messed up their ability to make a claim and get it processed correctly. Can they NEVER fix any problem that occurs?
When I originally wrote this, the claim was still in limbo – amount $97.10, not an earth shattering amount. I left a message for a tier 3 supervisor (who hadn’t returned my call). Their “possible” solution to this problem makes me do hours of work for them, because they made an error and does not guarantee a resolution.
In my case, they see the error, they know it occurred, they know why it occurred, and they admit they made it — but it’s incurable. I believe they really can fix it and have to have some procedure in place to do that. Do they think if they keep saying “denied”, “denied”, “denied” long enough I might just give up? Why should they make this so hard and give me all the work to do when it’s their error? Are they just trying to save themselves my $97.10?
My point of annoyance is, if this can happen, and obviously it does, why do they keep saying they can’t fix it? Someone can fix it. I know that it’s curable – I just can’t seem to find the person who can.
Addendum: This finally got resolved – they paid the lab and the lab refunded my $97.10. Lesson is that some things though deemed incurable, really aren’t! Persistance sometimes does pay.