“Two-thirds of beneficiary communication is more complex to read than Moby Dick…” Let’s start with EOBs!

When triaging my snail mail I quickly put all the Explanation of Benefits (EOBs) aside. Soon after I toss them into a garbage bag then throw them out without any review.

I have Medicare with secondary coverage from United, and I get sequential Explanations of Benefits (EOBS) from each.

Here are some of the reasons I can’t figure out whether or not my claims have been processed correctly.

– The Medicare and United EOBs are different and it is difficult to try to synchronize them

– Each has a separate deductible and they are hard to track

– United “outsources” certain categories of service such as rehab/chiropractic generating additional EOBs

– I also get a monthly Medicare Part D report, for the Prescription Drug benefit

– If Medicare doesn’t pay then United won’t either even if United would pay if it was primary. For a given provider the secondary co-pay is different depending on whether or not the provider is in or out of network with United, no matter what Medicare pays, if it pays

– Every provider codes claims differently so similar service at two providers may be coded and billed differently.

– When I got PT in two different places one charged me $20 per visit, the other calculated a co-pay for each visit.

– Some offices ask for co- payment at the visit, others way until after the claims are completed.

– United sends out-of-network payments to me, often with insufficient information to identify the provider.

– And United bundles out-of-network payments from several providers then I have to figure who I owe what and write separate checks to each.

– I am going to a chiropractor who accepts Medicare and is out-of-network for United so I do not know my out-of-pocket costs until I get the United EOBs.

-Sometimes I get a United denial because a provider has failed to file with Medicare first. So I have to ask the provider to send a claim to Medicare, adding months to the processing, and receipt of the two EOBs.

– Medicare and United have different appeal procedures. If I can’t link the EOBs it’s impossible to know where to appeal.

Some providers bill so efficiently that it seems like I get a Medicare EOB before I get home from the office visit!

Added confusion after each January 1st, e.g., now I get EOBs for 2018 where deductibles and copays are done, and for 2019 where they start over separately for Medicare and United (and each of its outsourced programs).

Recently I got a check for $37 from a hospital I use. No date of service.  No EOB. No explanation of what was provided.

Here’s a personal frustrating example:

I received a bill and paid $205 for a lab test done at a reference laboratory. No insurance claims had been processed.

After I followed up, in March I got an email: “I contacted XXX and spoke with ZZZ. Per ZZZ Medicare processed and made payment on one of the charges but denied the other (processed the $82.00 charge denied the $123.00 charge). He is confirming the reason for the denial for the second charge and will work with Medicare regarding processing it for payment. Currently you have a credit of $73.38 however Empire has not processed and paid for the $8.62 coinsurance applied by Medicare. ZZZ will submit that as well.”

It took months to get it resolved!

We are “collateral damage” in a war between hospitals and insurance companies. *

The obvious but unlikely solution is universal coding/ claims/ EOB by all providers, integrated to simplify tracking of a claim through primary and secondary insurers.

“Healthcare payers’ beneficiary communication efforts leave a lot to be desired, as organizations let considerations for low patient health literacy and other best practices fall by the wayside, according to a recent report from Visible Thread.

Currently, 86 percent of insurers are not effectively communicating with the 65 and older population, despite strong incentive to do so. With 15 percent of the country eligible for Medicare coverage, it’d behoove payers to cater to this population, the report authors explained…

But healthcare payers are not creating copy that meets those patient needs, the report continued. Six of the 30 surveyed payers use the recommended word density level. Fifty-six percent use the passive voice too often, and the average sentence is two times longer than recommended. Two-thirds of payers produce patient-facing content that is more complex to read than Moby Dick…

But complex explanations of benefits and other payer documents are making that trust difficult to come by. Payers that do not use adequate language to explain policies around pre-existing conditions, for example, are big stressors for patients. Patients who do not know what will and will not be covered in their plan have difficulty selecting an adequate plan…

Health payers looking to improve their beneficiary communication should work to reduce their sentence length, eliminate passive voice from their writing, choose less complex vocabulary, and adopt technology that can simplify copy, the report authors recommended…

“Instead of forcing people to continue to battle complexity, payers can invest in simplifying the ways consumers interact and engage with healthcare…”

Another study, conducted by NORC at the University of Chicago, revealed that complex benefits documents have led to numerous surprise medical bills…

The NORC at the University of Chicago survey found that 57 percent of patients had received a surprise medical bill as a result of unclear benefits explanations and low health literacy.

“Most Americans have been surprised by medical bills that they expected would be covered by their insurance,” Caroline Pearson, senior fellow at NORC at the University of Chicago, said in a statement. “This suggests that consumers may have difficulty understanding their insurance benefits or knowing which providers are included in their plan’s network.”

As consumerization continues to loom large in healthcare, it will be important for patients to be fully informed of all aspects, including access to clinical care and access to comprehensive payer coverage. To do this, payers must employ simpler language in beneficiary communication and engagement documents and be mindful of current patient health literacy levels.” (A)

to learn more about EOBs you might look at:

Understanding Your Explanation of Benefits (EOB) – How to Decipher Your Explanation of Benefits https://www.verywell.com/understanding-your-eob-1738641

Three “must read” articles:

Markups On Care Can Fatten Hospital Budgets — Even If Few Patients Foot The Full Bill, by Chad Terhune. Kaiser Health News. http://khn.org/news/markups-on-care-can-fatten-hospital-budgets-even-if-few-patients-foot-the-full-bill/

Those Indecipherable Medical Bills? New York Times. by Elisabeth Rosenthal. https://www.nytimes.com/2017/03/29/magazine/those-indecipherable-medical-bills-theyre-one-reason-health-care-costs-so-much.html

Donald Trump Did Something Right, by Elisabeth Rosenthal, https://www.nytimes.com/2019/01/21/opinion/trump-hospital-prices.html

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