Okay, I hate to indulge in conspiracy theory, but in this case I think I have it knocked out. There is no way insurance companies are really this stupid, their inability to process a claim correctly the first time has to be part of a larger, sinister plan. Of the over 84 claims made by my family in the last 5 months, roughly 90% have been done wrong in some form or another and I have had to call the company, taking 2 complete days off of work and numerous hours throughout subsequent weeks dealing with what, on the surface, appears to be ineptitude. That is until you realize the genius of their plan. If they misprocess claims, and when they do they are always in their favor monetarily, and I pay them, they win. See they don't apply the correct deductibles, they put doctors that are in network as out of network, simply decide they are only going to pay some random small amount, and it's up to us to catch em.
But here is where they are even smarter. Much like in chess, they hire "pawns," they call them "customer service reps" and they are the people sitting in the call centers waiting to ask you the same questions you just answered over the automated system in order to discourage you from asking any more questions. You know, you call up, you input or say your member ID, date of birth, maybe last 4 of your SSN, and then say what department you want 4 times because the automated speak and spell couldn't understand the word "claims" no matter how well you enunciate your words. THEN, when they actually get you to a human being, you have to repeat your member number and DOB. Why is that? Is it not on their screen? Finally, you get to ask your real question, knowing full well this person is not going to be able to answer your question. I've actually asked to skip right past them for the department I knew I would need, DENIED. I had to explain my issue in full, then wait for them to tell me they could not help me, they had to transfer me to.............wait for it..............THE DEPARTMENT I ASKED FOR WHEN I FIRST OPENED MY MOUTH!
Then, as in chess, once you move the pawns out of the way, you have access to the Rooks, Bishops, and Knights. Normally in chess, the Knight can jump the pawns, but in the insurance world, this is not permitted, see above statements. The Rooks, Knights, and Bishops are the people in the Resolution Departments. There is more than one btw.... You have the Rapid Resolution Department(an oxymoron if ever there was one, they are not "rapid" and rarely "resolve"), there is the Complex Adjustment Team, that's for the claims that require actual thought. And finally you have the Appeals Division. The Appeals Division is where you go, when the insurance company itself has screwed it up so bad, they can't fix it without a nice letter from you stating why they should. We've done 2 now, but it's early.
So now I know, it's a game to them, and I figured how they win it is to simply keep slow playing you, grinding you down until you either give up, or you've met your out of pocket max for the year, at which point it is in their benefit to process the claims correctly. If we really wanted health care reform in this country, this is where we'd start. Not adding IRS agents to go after people who don't buy health coverage, WTF is that about?
Okay, I am putting away my soapbox for now, rant over.
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