Note: Thanks to my friend, Frume Sarah, I recently signed up at “the red dress club” and now receive regular writing prompts twice each week. The first one—“gluttony”—arrived in my inbox earlier this week.
Dear Medical Insurance Provider:
It’s really very simple, and yet you just don’t seem to be able to get it right.
On March 9, you issued a $100 check to me as payment for services that I’d received from an out-of-network provider. Trouble was, you factored into your calculations a $25 co-pay that I (rightly) hadn’t paid. (Remember, this was an out-of-network provider and thus there was no co-pay.) And so I called you and listened to cheesy music until it was my turn. When you finally got on the phone, thank goodness, you understood what I was telling you, apologized for the error and submitted the claim for reprocessing. About a week later, a check for the additional balance due me arrived in the mail.
On April 18, you issued a $360 check to me as payment for services that I’d received from an in-network provider. This time the trouble was that—as is the practice with such providers—I’d paid the requisite $25 co-pay and expected that the doctor’s office would bill you. When I called to tell you that a check had been issued to me in error, you told me to sign it over to the provider. If I did that, however, he or she could conceivably be paid twice. And so the uncashed check sits in my ever-growing “Medical Insurance” file. One day, I’m sure you’ll figure out the error and come looking for that money, and I’ll just return the check to you.
Yesterday, you emailed an Explanation of Benefits to me that detailed payments due me for services that I’d received from a (different) out-of-network provider. Like the first time, though, you again factored into your calculations a $25 co-pay that I, once again rightly, hadn’t paid. And so once again, I called you, listened to cheesy music until you came on the line and, thankfully, understood what I was telling you, apologized for the error and submitted the claim for reprocessing. With any luck, when the payment arrives in the mail, it will be for the correct amount. Needless to say, I’m not too terribly optimistic that it will be.
So, Medical Insurance Provider, let me fill you in on how it’s done.
When I see a provider who is in your network, I’ll pay a $25 co-pay, the provider will bill you and you’ll pay him or her a predetermined negotiated rate—generally less than what he or she charges—for the service provided to me.
When I see a provider who is out of your network, I’ll submit a claim for the full amount, you’ll tell me that the usual and customary charge for that particular service is some amount less than what I was charged and then, if I’m lucky, you will, without factoring in a co-pay that I didn’t lay out, issue a check for 80 percent of the lesser amount.
I hope this information is helpful to you, Medical Insurance Provider, and that henceforth you’ll use these guidelines when processing my claims. Thank you for your careful consideration of this matter.