A Square Deal in Seven Scenes

Setting:  Exam room of fancy medical office in fancy city. Patient Mercy has just been examined, diagnosed, and received a treatment recommendation from Doctor. Patient  Mercy has agreed to receive the treatment. Mercy sits in chair staring at X-rays.

Scene One:  Doctor exits exam room, Admin Lady comes in. 

Admin Lady:  We checked your insurance. You are not covered for this procedure at all. The cost will be $2,600.00. But we can perform the procedure in two sessions for $1,300.00 each.

Mercy:  Yikes. (Pauses to think.) Well, I’ve got have it done. Book the first session and I’ll save up some money.

Scene Two:  Three weeks before surgery, over the phone.

Mercy:  I’ve got better insurance now. It’s new. It covers my treatment. Can I send you my card?

Admin Lady:  No, we don’t need it. Just read me some numbers from the card. We will check it and call you back with a new price.

Scene Three:  Two weeks before surgery, also over the phone.

Mercy:  I never heard from you. Surgery is coming up. What will I owe you?

Admin Lady:  Your new insurance company has never heard of you. You are still not covered.

Mercy:  Can I send you my insurance card? The card with my name on it? There’s a phone number for insurance claims on it too.

Admin Lady:  No, we don’t need it. Just give me that number.

Scene Four:  One week before surgery, over the phone.

Mercy:  I never heard from you. Surgery is coming up. What will I owe you?

Admin Lady:  We still don’t know.  We will call you back.

Scene Five:  Day before surgery, also over the phone.

Mercy:  I never heard from you. Surgery is tomorrow. What will I owe you?

Admin Lady:  Your insurance company says you are not in the system. You’re not covered. But we will charge you $900.00 for the first treatment if you want to keep the appointment. You’ll have to pay up front. Then you can schedule the second treatment and work it out with your insurer.

Mercy:  This can’t be right. I bought the policy because it covered this procedure. Can I send you a copy of my card?

Admin Lady:  No, we don’t need it. We’ve already called. The cost is $900.00. Do you want to keep the appointment or not?

Mercy:  Keep the appointment. There must be a mistake. I know I’m covered. I will investigate. (Ends call)

Mercy:  (dials phone)  Insurance?

Insurer:  Hi there.

Mercy:  Provider says I am not covered. I’m not in your system. I don’t exist. Please help.

Insurer:  Hmmm … (sound of typing) You do exist. We see you. You are covered. You’ve been covered for three weeks now.

Mercy:  How much would I owe my provider for this procedure?

Insurer:  We pay 70%. You pay 30%.

Mercy:  That’s what I thought. And they can call you at this number?

Insurer:  Yep.

Phone call ends. Mercy grabs a calculator and punches keys. End scene.

Scene Six:  Next day, day of surgery, over the phone, during business hours.

Computer Voice:  If you’ve reached this recording during business hours, please leave a message. Someone will call you back.

Mercy to Computer:  Good news!  I exist!  I’m covered! I’m scheduled for surgery today.  Please call me back.

Same morning, Mercy’s phone rings

Admin Lady:  I got your message. This is odd. Which number did you call?

Mercy:  The same number I’ve been giving you for three weeks.

Admin Lady:  Can you give it to me again?  Maybe I am calling the wrong number.

Mercy:  I called them myself. My insurance company confirms I exist. I’m in the system. I have coverage. I should owe you $400.00 for the procedure. I can bring you the card I’ve tried to give you three times. Or send you a copy now.

Admin Lady:  No, I don’t need your card. I will call them again.

Mercy:  But I already did.

Admin Lady:  They told me yesterday you are not covered. I’ll call them again and then conference you in so you can hear it for yourself. Keep your phone nearby.

Mercy:  (Stunned) Wow. Okay. (recites phone number for insurance company and ID number yet again)

Many minutes later, Mercy’s phone rings.

Admin Lady:  You’re not covered, like I told you yesterday. I tried to conference you in but it wouldn’t work. The cost is $900.00.

Mercy:  I am covered. I called and confirmed coverage myself. I bought the policy specifically for this procedure. I’ve been covered for the entire time we’ve been exchanging these calls.

Admin Lady:  Nope.

Mercy:  Then cancel my surgery. I will ask a different provider for this treatment.

Admin Lady:  Are you sure you want to do that? I’m trying to help you out here.

Mercy:  (laughs) Yes, I’m sure I don’t want to pay $900.00 for a $400.00 procedure. Cancel it. And thanks for helping me out.

Immediately afterward, over the phone.

Insurer:  Hi again.

Mercy:  Provider still insisted I’m not covered. Claims they checked with you this morning. Did they? Am I covered?

Insurer:  Yes ma’am, you’re still covered. No, they didn’t check.

Mercy:  (thoughtful) K.  Thanks.

Mercy in soliloquy:  This doesn’t make sense. When in the history of insurance has a provider opted not to submit a claim for a covered procedure? They’d rather have no money?

Scene Seven:  Next day, Mercy’s phone rings.

Admin Lady:  Just wanted you to know we tried again. You were covered after all. Someone made a mistake. We still want to treat you. Would you like to reschedule your surgery?

Mercy:  Who made the mistake?

Admin Lady:  We’re not sure.

Mercy:  I think it was probably my mistake. I tipped my hand during the initial exam, didn’t I?

Admin Lady:  What do you mean?

Mercy:  I originally agreed to pay the full price out-of-pocket so you knew I was good for the money, right? I probably shouldn’t have done that. You had no incentive to hassle with insurance.

Admin Lady:  Um.

Mercy:  But then I backed out, and no procedure at all means no payment at all, so now it is suddenly worthwhile to hassle with my insurance. I probably should have made things easier on both of us by pretending I couldn’t afford it from the beginning. How much would you have charged my insurer, by the way? Had you been able to confirm coverage?

Admin Lady:  (firmly and enthusiastically) But we have confirmed coverage! You can come on in and get treated, no problem. I can make the appointment for you right now.

Mercy:  How much will you charge my insurer?

Admin Lady:  We will bill you for 30%.

Mercy:  (firmly) How much will you charge my insurer?

Admin Lady:  Your insurer covers 70%.

Mercy:  (more firmly) How much will you charge my insurer?

Admin Lady:  We will send you a statement once the claim is processed.

Mercy:  But how much will you claim for the procedure?

Admin Lady:  You’ll see that amount on your statement. And your insurer will send you an explanation of the claim as well.

Mercy:  Tell me now.

Admin Lady:  I can’t do that.

Mercy:  Me neither.

The end.

 

 

 

 

 

 

 

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