Sometimes, It's Personal

John Kelly

One thing about working in healthcare is that in general, you can feel some good in the work you do. Even when so many aspersions are cast upon a system that frequently doesn't work at all well for patients, you can invest your work with meaning knowing that you approach your job each day trying to make that system respond positively to people in need. The challenge of porting the technology wins we experience in our collective personal and professional lives over to our healthcare domain continues to offer a lot of hope that things can and will get better; even though we have stumbled frequently throughout the last decade of massive technology investment.

One seemingly simple opportunity where we've failed miserably is the area of Claims attachments and requests by payers to providers for additional clinical information necessary to pay a claim. While we argue over billing and payment rules, enveloping and content standards, and the return on investment for all the stakeholders, bad things are happening to our patients and customers. Having recently lost my wife to a long battle with cancer, of all the difficult things we had to deal with, the most needless of pains and indignities was getting Explanation of Payment letters indicating we had patient responsibility assignments which many times over many years exceeded $50,000-$60,0000. Of course when you call your providers of coverage and care you get told that the documentation to substantiate the claim has simultaneously been sent and not received for months on end.

Physician and hospital billers say they've done what they could and insurance companies say they have no choice but to deny the claim, “patient responsibility” after 60 days. Of course, both parties assure you that things will eventually settle and it will get paid upon appeal. Having spent a lifetime in this industry, I know which buttons to push and what to say. I do know the bill will get paid. However, when a loved one is facing so much pain and anxiety, those letters from both the providers and payers ceaselessly arrive and are the source of much pain and needless anxiety. It's not rationale but it is real.

When you're losing all you hold dear, little stupid things take on great significance and while a disease takes your dignity, an apparently uncaring system designed to fail robs you of peace of mind. I've spent decades working on this system. I pretty much know it inside and out. I know this little attachments piece can readily be fixed with the technology at hand if only it were deemed a collective priority. And I continue to feel pain for all those who don't know what I know and who can't manage the system in the manner it requires. I'm pretty passionate about attachments these days. It's personal.