IBJOpinion

HETRICK: Here's a little ditty 'bout health insurance reform

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Bruce Hetrick

Just before Christmas, I received a nasty-gram in the mail from a firm called ORS.

ORS, I learned from the letterhead, stands for Overpayment Recovery Services, a firm based in Franklin, Tenn.

The letter said ORS is a division of AIM Healthcare Services Inc., also from Tennessee.

I looked up AIM on the Web. The home-page headline says: “AIM’s data-driven model directly connects payers and providers.”

It goes on to say: “We are in a unique position to see the entire ‘life of a claim’ from pre-admission on the provider-end to recovery from the payer perspective. Our experience and intelligence encompasses over 1,100 commercial and government payer clients representing 92-million member lives, as well as more than 1,700 hospital and health system clients.”

In other words, I had met Big Brother and he was in my mailbox.

The letter said ORS “has been contracted by Anthem Blue Cross and Blue Shield [which is headquartered a few blocks from my Indianapolis home] to help resolve pharmacy claims that Anthem Blue Cross and Blue Shield paid at a time when you were not eligible for pharmacy benefits.”

Uh-oh.

Finally, to make sure I got all the weasel words and corporate-speak through my thick skull, the letter said: “This is an attempt to collect a debt and any information obtained will be used for that purpose. This is a communication from a debt collector.”

Aha!

The charge in question is a whopper: $32.97 for insulin needles that cost me nothing out-of-pocket.

This all stems from closing my business and losing my company-funded Anthem health insurance on Sept. 30, 2011. That night at midnight, however, I went on my wife’s insurance plan. The insurer: Anthem.

A few weeks later, I needed a refill on my needles. Knowing there was no charge, I phoned in a refill, picked up the script, and thought nothing of it.

Naughty me.

So rather than look up my Social Security number and transfer the charge from one policy to another—or, heaven forbid, call me—Anthem decided to pay ORS, which is part of AIM, to collect $32.97 from itself. And to make it work, I had to play the Tom Cruise role in “Mission: Impossible.”

Along with the nasty-gram, you see, ORS sent me a page of instructions. If I wanted to dispute the $32.97 claim (which, given the premiums I pay, I did) ORS said I had to:

• Take a copy of their letter to the pharmacy that filled the prescription.

• Ask for a copy of my prescription profile.

• Send a copy of the profile and the ORS letter to my current insurance carrier’s claims department.

• Contact my current insurance carrier’s claims department for assistance in refiling the claim with them.

• Allow seven to 10 days for my current insurance carrier’s claims department to receive my claim, then nag them to make sure they’d received it and planned to pay it.

• Call ORS to tell them what my current insurance carrier’s claims department had to say.

• Wait 30 to 45 days for the claim to be processed.

• Once my current insurance company issued a refund check, deposit the check into my personal bank account.

• Send a personal check or money order to ORS for the amount due in full.

There was time pressure, too. Even though my current insurer (Anthem) was likely to take 30 to 45 days to write a check for my former insurer (Anthem), ORS, which is part if AIM, wanted me to know the consequences at hand: “Unless you notify this office within 30 days after receiving this notice that you dispute the validity of this debt or any portion thereof, this office will assume this debt is valid.”

Whoa.

On NPR the other day, I heard a story about the Affordable Care Act, that much-maligned legislation known affectionately as “Obamacare.”

The story discussed a provision in the law that says health insurance companies can’t use more than 20 percent of premium dollars for overhead and profit. In other words, 80 percent of my medical care dollars must go toward actual medical care.

If overhead and profit exceed 20 percent, health insurers must issue rebates to customers.

The story said many states are fighting this provision and that some insurance companies say they’re struggling to meet the 80/20 requirement by the 2012 deadline.

Robert Zirkelbach, spokesman for America’s Health Insurance Plans, the national lobbying group for insurance companies, told NPR, “The new regulation tries to make insurers responsible for rising premiums, when really the problem lies with doctors, hospitals, and drug and device companies.”

Hmm.

Knowing that Anthem is paying ORS, which is part of AIM, to collect $32.97 from itself—all while making the customer jump through hoops—perhaps the doctors, hospitals, drug and device companies (and, heaven forbid, consumers) would like to point the proverbial finger in the opposite direction.•

__________

Hetrick is an Indianapolis-based writer, speaker and public relations consultant. His column appears twice a month. He can be reached at bhetrick@ibj.com.

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