Re: No Experience

[Danni R.]

THis is my personal opinion based on my investigations into reading insurance company filings with the SEC.  I think one of our huge problems is that CEOs strive to show a profit.  They show a profit they get a multimilion dollar bonus and they get to keep their jobs earning megamillions in salary, billions in stock options, living in company paid mansions, flying on G-5 corporate jets,  going to work and back in a limosine with driver, memberships in the high priced private country clubs, and free healthcare.  One HMO CEO tookout a 2 million dollar loan,  He never had to pay it back after showing a profit.  He also got $100,000 to pay for the limo and driver.   

Im not a graduate of the Wharton School of Business but common sense says, you show a profit by increasing revenue and decreasing outgoing costs.  YOU increase revenue by raising insurance premiums. YOu decrease outgoing costs by (a)  deny claims,  (b) deny benefits, (c)  pay doctors as little as possible through pisspoor contracts and creating low usual and customary reimbursment allowables, and making you pay more out of pocket by increasing your copays and deducibles.   You raise a deductible to $5,000, very few claims are actually paid by the insurance company, you delay payment on claims by denying for timely filing or some other reason or you pend claims as long as you can, and (d)  you lay off company employees, especially those close to retirement so they dont get their retirement.   

If anyone has time, I recommend reading the book The Rainmaker by John Grisham or renting the movie.  I just bought the book, The Appeal.  Havent read it yet.  Am busy working on an Idiots Guide to Medical Billing and Coding book. 

So, that's how it works, the cookie crumbles, the mop flops??? I sort of knew this, but I feel enlightened by you spelling it out for me. No, I am obviously not a Wharton either. Ha, ha.

About the book, are you co-authoring, or writing it solo?

[Steve Verno]

THis is my personal opinion based on my investigations into reading insurance company filings with the SEC.  I think one of our huge problems is that CEOs strive to show a profit.  They show a profit they get a multimilion dollar bonus and they get to keep their jobs earning megamillions in salary, billions in stock options, living in company paid mansions, flying on G-5 corporate jets,  going to work and back in a limosine with driver, memberships in the high priced private country clubs, and free healthcare.  One HMO CEO tookout a 2 million dollar loan,  He never had to pay it back after showing a profit.  He also got $100,000 to pay for the limo and driver.   

Im not a graduate of the Wharton School of Business but common sense says, you show a profit by increasing revenue and decreasing outgoing costs.  YOU increase revenue by raising insurance premiums. YOu decrease outgoing costs by (a)  deny claims,  (b) deny benefits, (c)  pay doctors as little as possible through pisspoor contracts and creating low usual and customary reimbursment allowables, and making you pay more out of pocket by increasing your copays and deducibles.   You raise a deductible to $5,000, very few claims are actually paid by the insurance company, you delay payment on claims by denying for timely filing or some other reason or you pend claims as long as you can, and (d)  you lay off company employees, especially those close to retirement so they dont get their retirement.   

If anyone has time, I recommend reading the book The Rainmaker by John Grisham or renting the movie.  I just bought the book, The Appeal.  Havent read it yet.  Am busy working on an Idiots Guide to Medical Billing and Coding book. 

[Pay_My_Claims]

Steve,
I'm going to be REALLY honest with you here. Having worked all those years with the insurance carriers, when I did transition to billing I had a VERY difficult time with exactly what you described. There is no-doubt in my mind we were conditioned and trained to "DENY"..  But I'll tell you what pushed me over the edge to go into billing (aside from having a client first.) I was working a case of a young girl who had a liver/kidney transplant when she was 4, this little girls case was my case since she was born, he father worked for a very large auto manufacturing company and they had pretty decent coverage. To make a long story short (or try to) her transplant rejected and she was then diagnosed with another fatal illness. The little girl would not live to see 7 years old. A new donor was found and when the claim came in the policy Max of $1Mil was exceeded with the last hospital stay.
I sat there at my computer screen actually crying because I couldn't override the denial. (my payment threshold was $20K) I did a full write-up of the denial for my tech, claims examiners can appeal system denials to higher level tech's. 2 days later my tech's instructions were to deny as over policy max. Not only did I not want to process that denial but sign my name to the denial letter.  I won't go into specifics on how I did it, but I was able to split the claim 4 times, go down to check processing and actually mail out the checks myself. I waited another 10 days and resigned, I kept the phone number of the parents of the little girl, I stayed in touch with them and don't ask me how but the pmts were never flagged or caught, the insured's threshold was later raised administratively ..
What I did was wrong but I don't feel it was wrong.  And yes the little girl died in 1997 
years later I ran into my quality supervisor at a bar and I told her what I had done and her response : "I know, it never got flagged" 
My point to that story was to give you a HUMAN side to the person behind the desk at the insurance company. When I started billing and consulting it was hard in the beginning to overcome the conditioning and training however my experience there gave me a real inside edge in dealing with the carriers on behalf of the doctors. I tried to completely change the process but later came to realize I could find balance to where my experience there was a PLUS for providers. There are so many little secrets claims examiners have to "finding ways" and when you know that you can use that to your advantage and I have and continue to use those secrets <g>
There are also a lot of misconceptions about claims examiners..the biggest myth being "We throw claims away" LOL I worked at Prudential, USLife, and a short while at Cigna and BCBS and I can tell you that it was Absolutely.... POSITIVELY impossible to get rid of a claim unless you stood in the mail room, there was no secret file 86 or bin 86..and that was for paper claims. Electronic claims..forget it, if they came through the edits and made it to the main claim batching system they were there. That's not to say they didn't sit in a pending file 
Well I can go on about this ... I really did like being a claims examiner.. and I like billing/consulting.. which is why I think I would have made an excellent criminal defense attorney <G>
 

All I can say is WOW!!! I worked at the hospital and worked HemOnc, Transplants, NeuroSurgery, Trauma, Ortho, Neurology, Cardiology, so I truly know how you feel.
BTW I used to love BCBS until I started working for DME....
We had a lot of our nurses leave Cigna....(NC)
C

[Steve Verno]

Lynn

many people working at insurance companies are excellent. I had a close friend working at my worst enemy, BCBS. I would tel him he was so full of garbage when he would try to stick to company policy and he let it roll off his back.  He was the only one who earned my respect and friendship.   

On a side note, I once had to go to a large insuance company for a week.  Getting past the gate was harder than getting into the White House or Pentagon. I had to be escorted to a parking spot.  Then I had to me escorted everywhere in the building, including the bathroom and cafeteria.  WHen I walked by a desk, they would put any materials away and had their screens set so I couldnt see them as I walked by.  I will say they had an excellent cafeteria.  They also had a fanastic exercise room for the employees.  I felt like I was in Stepford when I was there.   When I left the building, they searched my briefcase to make sure I wasnt carrying anything out that was their property.  On my next to last day, I met the nurse reviewer.  She displayed no emotion whatsoever.  I was arguing a critical care claim unpaid.  THe nurse told me that she could not approve the CPR.  I showed her the NCCI and CPT manual.  An employee in the room came over and said, "Thats the opposite of what's in our manual." The nurse told him not to say anything more and she left the room.  She still denied for inclusive. I went into the next building and asked to see the CEO. he wasnt in (Gee no kidding, probably flying around in his G-5). The employee who opened his mouth was terminated that day.   During lunch, they had Televisions all around the room.  No TV programs, just commercials and video notices of their products.  (Twilight Zone opening music playing now)

I know insurance reps are normal people.  Many make excellent billers.  You guys see things we dont see. I can imagine the frustration ove the volume of claims that come across with missing info or coding issues.  Not to mention a mad customer. This same insurance company would try to call me with the patient on the other line.  It was an intimidation attempt on their part.  One patient wasnt happy, when I presented my information, when she was told she owed $200 that was a mistake and wasnt applied to her deductible.   I biled her for the $200 in the first place.  The EOB said she didnt owe the money because a network discount was taken, We weren't in network. 

As Ive said many times, Florida is a different world, as billers, we see many things others dont see in other states.  That is why we have so many messed up laws.   

In closing, in 1996, the State of Florida established a panel to research HMO problems brought forth by doctors, hospitals and the various medical associations.  A doctor friend of mine was on the panel.  AT one meeting, an HMO doctor told the doctors, all ER docs, that they dont know what an emergency was. GASP!  WHen it was my turn, I brought more than 500 denial letters signed by this doctor denying the emergency.  One-  72 year old man having a heart attack.  Another - 5 year old with fractures of both radius bones, Another a small girl bashed against the bathroom door by her father and sustained a skull fracture.,  The panel asked me to stop and I said I had at least 500 more.  The HMO doctor tried to find the exit quickly.  This panel was responsible to changing the HMO law at that time. The HMO law required authorization for emergencies.  Not no more.  Nice thing to me, The HMO went out of business. 

Organic

The test I had to take was a 4 hour test.  If you know coding and billing it wasnt hard.  For example, which of the following codes requires modifier 25 when billed with another procedure.  If you knew about modifier 25, the answer showing an E/M code was the logical answer.  The other answers provided were hcpcs codes for supplies.  I didnt have any books when taking the test, but they werent needed.  Another example. Mr. Jones had a 2cm surgical repair to his index finger. The answers would be the correct repair code, an x-ray code, a lab code or a hcpcs code that were obvious wrong answers.  If you knew the basics of minor repairs, then the answer was a process of elimination.   If it asked for a modifier for distinct Services, you hit an F-key for a look up.  However, it wasnt hard to know this would have been modifier 59 and not modifier 22, or 25 or 99.   Again, I had  hours to take the tes. The time went so quick.  I was done and didnt know it.  Im sure you'll do fine.

LInda No one can blame you for anything.  You tried your best and did your best.  You are one of the most respected people in the profession.  I was personally impressed with you when we met those many years ago at my first conference. 

Just to let you know, some people think I'm a mean and crazy SOB.  People who know me know I can be a teddy bear inside.  Im also protective of my doctors and patients like a gander.  I doubt I could work like you did or stick with it like you did.

You and I probably have a thousand stories we could share or write a book about. 

[Pay_My_Claims]

Sorry, never temp'ed medical billing When I applied they did call me for a job but didn't do a test. I was hired on my credentials (didn't take job)

[Danni R.]

Back in November, I was contacted by a Florida Insurance company.  They wanted a certified biller and coder to work in the claims department reviewing claims. It was a long process. In my last interview, the question asked of me that caused me to not be hired was, "If you had to make a decision for the insurance company or for the doctor, who would you choose." I said I have to do what is right,  If the insurance company is right, my decision would be for the insurance company and if the doctor is right my decision would be for the doctor.   I was told they refused to hire me because of my loyalty to the doctors.  They then asked me to find someone for the position.  Naturally I was to research and recruit for free. 

Many years ago, I was asked by a provider to do an audit of his practice.  The biller he hired used to work for an insurance company, one of the large ones.  SHe and I knew mutual people when I used to be in new Englad and would visit the corporate office in Hartford.  I found the problem immediately.   She always accepted denials and never appealed. The claim would be denied for timely filing and when asked why she didnt appeal it because it was sent within the 6 months allowed by Florida Law.  If the insurance paid less than charges, she refused to appeal. Her response was "They are correct and I would have denied the appeal for these denials.  I said you sent the claim timely, She responded, es, but the insurance company was correct. They have a 90 day timeframe.  I replied, you sent it within 1 day of the date of service, not 91 days.  Her loyalties remained with the insurance company and it cost the doctor thousands of dollars. When asked why she didnt bill patients for their deductibles, her reply is I dont believe in patient billing because that is how I was taught.  This particular insurance company, which will remain nameless, had a policy of not allowing doctors to bill their members.  I said, the patient owes the deductible and you have to make an attempt to collect it.  Her reply was, I dont bill patients. I said, thats your job.  WHen presented with this, he had a meeting with her to discuss her changing her personal ideals rather than let her go.  She refused.  Sadly he let her go. This does not happen with everyone that worked for an insurance company.  A Pediatrician friend once hired a former insurance rep after I recommended he terminate his billing company an bring his billing in house.  He did and she was the best thing since sliced bread.   She learned how to improve her appeals and brought in much more money than before, for the provider.

SO, follow Linda's advice for job prospects.

Thats an excellent suggestion. 

Your answer was the noble, and right one, however, corporations demand loyalty, not morals. In the end, though, it is YOU who you will have to live with. So, be smart, but never a sell-out.

[Steve Verno]

Back in November, I was contacted by a Florida Insurance company.  They wanted a certified biller and coder to work in the claims department reviewing claims. It was a long process. In my last interview, the question asked of me that caused me to not be hired was, "If you had to make a decision for the insurance company or for the doctor, who would you choose." I said I have to do what is right,  If the insurance company is right, my decision would be for the insurance company and if the doctor is right my decision would be for the doctor.   I was told they refused to hire me because of my loyalty to the doctors.  They then asked me to find someone for the position.  Naturally I was to research and recruit for free. 

Many years ago, I was asked by a provider to do an audit of his practice.  The biller he hired used to work for an insurance company, one of the large ones.  SHe and I knew mutual people when I used to be in new Englad and would visit the corporate office in Hartford.  I found the problem immediately.   She always accepted denials and never appealed. The claim would be denied for timely filing and when asked why she didnt appeal it because it was sent within the 6 months allowed by Florida Law.  If the insurance paid less than charges, she refused to appeal. Her response was "They are correct and I would have denied the appeal for these denials.  I said you sent the claim timely, She responded, es, but the insurance company was correct. They have a 90 day timeframe.  I replied, you sent it within 1 day of the date of service, not 91 days.  Her loyalties remained with the insurance company and it cost the doctor thousands of dollars. When asked why she didnt bill patients for their deductibles, her reply is I dont believe in patient billing because that is how I was taught.  This particular insurance company, which will remain nameless, had a policy of not allowing doctors to bill their members.  I said, the patient owes the deductible and you have to make an attempt to collect it.  Her reply was, I dont bill patients. I said, thats your job.  WHen presented with this, he had a meeting with her to discuss her changing her personal ideals rather than let her go.  She refused.  Sadly he let her go. This does not happen with everyone that worked for an insurance company.  A Pediatrician friend once hired a former insurance rep after I recommended he terminate his billing company an bring his billing in house.  He did and she was the best thing since sliced bread.   She learned how to improve her appeals and brought in much more money than before, for the provider.

SO, follow Linda's advice for job prospects.

Thats an excellent suggestion. 

[Pay_My_Claims]

just googled it............Thanks!!!

[Danni R.]

I, too, was hired right at the place where I did my externship. I once wrote a little article on "overcoming lack of experience" subject for medical assistants. However, if you search Google for "overcoming lack of experience" you'll get even more tips.

[Steve Verno]

if you excell, some internships could turn into permanent positions.

Last year, I started as a temp, one of 4 temps. 
One of them did an outstanding job that her temp position became permanent. 

[Pay_My_Claims]

You may have to start out entry level at the front desk check in/out. They assist with billing doing verifications and entering the charge slips. This way you have your degree, your internship and some front desk experience.

Good blessings.