Follow-up: An Example of Insurance Companies Focusing on Profits, Not Patients.

I received a letter today from Deseret Mutual Benefit Administrators (DMBA) re: an appeal I had filed on behalf of one of their members (our patient).  As I described in my previous post, I work very hard to provide our patients with accurate information as it relates to their out of pocket expense.  I had contacted DMBA prior to providing services to their client and was told that their plan would pay 100% of allowable charges after co-pay.  This means that the patient is only responsible to pay their co-pay, DMBA would pay the rest. Great news, right? Well, based on my past experience, too good of news.  So, we called DMBA a second time and talked to a separate representative.  She provided the same information, 100% of allowable charges after co-pay. The reason this sounds too good to be true is that our office is an out-of-network provider for DMBA, which both representatives were aware of. Logic would hold that the insurance company should know their benefit information.

We completed the evaluation and sent the billing to DMBA.  We received an EOB (explanation of benefits) along with payment. DMBA sent 60% payment on the allowable charges. I called and explained that we had been told by TWO of their representatives that they would pay 100%.  I was instructed to file an appeal.  

I received the appeal decision today.  Although DMBA acknowledges providing us with incorrect information (they reviewed both phone call recordings), their obligation is to pay as outlined in the "member handbook". So, who loses?  First off, the patient, because they are ultimately responsible for the incurred charges.  Second, the provider.  The patient made the decision to pursue testing based on the estimate I provided and may not have the financial means to pay for the services.  It is not uncommon in this situation for the patient to take out their frustration at the provider instead of where it rightly belongs, on the insurance company.

The denial letter also stated that, since the service was "medically necessary", it would have occurred regardless of the percentage the plan paid. I think the patient would strongly disagree.  They had other choices.  They could have taken responsibility for submitting the billing paperwork directly to their insurance, allowing them to be eligible for the cheaper "self-pay" rate. They could have also chosen an "in-network" provider that would have been reimbursed 100%. Everyone has a right to know what something is going to cost.  It frustrates me that in healthcare, this answer can be so hard to come by.


I still can't understand how an insurance company acknowledges providing incorrect information but won't take accountability for it.  I'm sooo frustrated!  I have offered to help the patient file their own appeal. For most patients, this is an intimating process and many just choose to pay (or not pay) the bill.