My Recent Adventure In Health Care Land.

I had a colonoscopy about two months ago. If you are over age 50, you should have one too.

Happily for all of us, that’s not what this is about. There will be no further mention of my colon in this post.

The procedure is routine. Mine was performed at a hospital here in Chicago, by a gastroenterologist who happens to be the Gastroenterology Section Chief at that hospital. He was recommended by my internist. It was out-patient, in and out in a few hours. Everything was normal. Routine, routine, routine.

My health insurance is with Blue Cross Blue Shield of Illinois (BCBSIL). As I am self-employed, it is an individual policy. I’ve had it for about 20 years, ever since I came to Chicago. It is a Preferred Provider Organization (PPO) plan so I can see any doctor, but I have to use in-network hospitals. There is a deductible and, after that, it pays at least 80 percent of covered charges.

For purposes of this post, that’s enough detail. The coverage is pretty standard, nothing exotic, and it’s not cheap.

My plan does not, as some do, require advance approval for this type of procedure, but I called BCBSIL anyway to make sure everything was covered. They assured me it was.

I’m a pretty healthy guy, but I’ve had enough medical care of various kinds over the years to know the drill with billing and insurance. Everybody gets your insurance information and sends their bills first to the insurance company, which pays the amount it believes it owes. Then the providers come after you for the rest. You expect to receive separate bills from the doctor and hospital, maybe another one for outside lab services, and maybe one or more from other practitioners, such as a pathologist or anesthesiologist.

When the bills start to come, the easiest way to process them is to take the Explanation of Benefits (EOB) reports from the insurance company and match them up with the provider invoices. You should have an EOB for each bill and all of the numbers should agree, including the number you care most about, the amount you owe.

This is my first gripe. When I take my Buick in for repairs, I don’t get separate bills from the mechanic, garage, and parts department. If the work is covered by warranty, I don’t get another envelope full of paperwork about that. I get one bill and it says, “here’s what we did, here’s how much you owe us.” There is no real reason health care can’t be just as straightforward.

But it isn’t.

Although everything should have been routine, in the case of my recent procedure there was a billing problem. BCBSIL disallowed almost $1,500 in lab charges that the EOB labeled “routine lab services.” I immediately called BCBSIL and the representative explained that “routine lab services” are not covered by my policy. I countered that the lab services were not “routine” but were a necessary part of a covered procedure. She agreed that what I described sounded like something which should have been coded as “medical lab” or “surgical pathology,” not “routine lab services,” but at any rate they could not change the coding. That would have to be done by the provider who submitted the charges.

Gripe number two. I maintain that “customer service” in most businesses means “solve the customer’s problem,” but that’s not what it means in the health care business. The ball was back in my court.

So I called the hospital. Their representative agreed that it sounded like a coding error. She conferred with the hospital’s coding department and everyone seemed to agree that pathology services rendered as part of this procedure should not be considered “routine lab services” by anyone.

The coding department’s suggestion, forwarded to me by the hospital’s customer service representative, was that I ask my physician to fax his orders from the procedure to the coding department. Presumably, this would allow them to recode the charges and resubmit them to BCBSIL.

Once again, an opportunity for a customer service department to provide actual customer service was missed.

Gripe number three. The system seems designed so that everyone can say, “it’s not my job, it’s not my fault,” and pass the buck.

I spoke with my physician, explained the situation, and told him the proposed solution. He stated that he understood the problem and would contact the hospital to resolve it. After our initial conversation, he called me back two more times just to let me know he was still working on it, and finally, about two weeks later, to say that it was resolved.

It was a coding error, as everyone knew it would be. It got fixed but the person who fixed it wasn’t a customer service representative, it was a board-certified gastroenterologist with 25-years of practice experience, who had to spend his valuable time resolving a coding error. Gripe number four, in the health care industry, everything will be done in the most expensive way possible.

My story is as common as it is tedious. The needless complexity of health care billing adds tremendously to the already absurdly high cost of health care here in America. Liberals seem to think a government-run plan of some sort is the solution, while Conservatives are entirely focused on thwarting the Liberals.

While I share their distrust of government programs, I don’t see how we can accept the status quo either. The free market has worked its magic in terms of providing quality, but the cost is breaking our backs. It’s not that great health care isn’t worth paying for, it’s that we can see exactly where all the waste is, but no one can seem to root it out. For individual consumers, when even the simplest problem occurs, it takes a task force to solve it.

I have some professional experience in the health benefits field and know a lot more about it than the average person does, so I probably handled the situation as efficiently as it could have been handled. I still had to make several telephone calls, wait for call-backs, sit on hold for extended periods of time, and do other time-consuming tasks. At least two different customer service representatives spent some time on it, as did the physician, and who knows who else. The hospital has a customer service department, a billing department, and a coding department, but they couldn’t fix it without the physician getting involved too. All of that “service” had to be paid for out of the proceeds of that procedure. I wonder how much it would really cost, with all due safeguards, but without all of the “extras,” such as layers of billing complexity, the indigent care “tax,” the cost of excessive liability insurance, and everything else that gets larded into the cost of basic health care.

Everyone agrees that the system is broken but all proposed solutions have so far eluded consensus.

As important as health care is, and as good as the product itself is, the system through which it is delivered is ridiculous. The best symbol of its absurdity is the fact that critical therapeutic information is still communicated from one highly-trained and highly-compensated practitioner to another solely through scribbles on scraps of paper, physically carried from one practitioner to the other by the patient. Only now is the system starting to figure out how to get prescriptions from doctors to pharmacists electronically, and that’s only happening because the Federal Government mandated it as part of the Medicare Part D program.

As usual, politicians are talking about all of the wrong things. It’s not about getting coverage for the uninsured. It’s about reforming, from top to bottom, all of the non-medical parts of a badly broken system so people can afford the care they need.