The Patient Who Knew Too Much

Update: This post was a daily winner at Everyday Hogwash!

Friday, I received in the mail an Explanation of Benefits (EOB, for those of you in the insurance world) from a certain health insurance company in our area that I used to work for. My employment there has nothing to do with this story, but it does prove that I do know how medical claims are handled and processed, because I used to be the one doing that.

This particular insurance company had been our medical insurance (through the Webmaster) two years ago. Recently, he went and had his yearly physical. His company, due to rising costs, has switched insurance companies twice since his last physical. So when he went in, he presented them with his new insurance card, paid the copay, badda-bing, badda-bang! We got our EOB from the current insurance company a week or so ago, and everything was in order.

Now I am getting an EOB from the former insurance company, telling me that the lab work charges from the Webmaster’s physical are being denied because “patient was not insured at time of service.” Well, yes, he was, just not by YOU.

However, this is not the insurance company’s fault. They received the claim from the doctor’s office and processed it properly. It is the family medical clinic that the Webmaster went to who screwed up. And it had to be them, since I had already gotten the EOB from our current insurance company that said his actual office visit was covered, with copay.

So, as the Munchkin is napping, I gather up the EOB from the old insurance company, the office’s phone number, and my purse so I can get at our current insurance card if needed. It is at this point that Baby Boy decides that he needs a snack. I carefully dialed the office and then, balancing my son on the nursing pillow on my lap, plug him in and wait on hold for first the receptionist to actually answer my call (3 minutes) and then the bookkeeper to actually deal with my complaint (another 3 minutes).

Baby Boy decides to switch to side two while I am on hold. Fortunately, I have a long neck and can keep the phone in place while hooking and unhooking a nursing bra.
I finally get the bookkeeper. “Can you tell me what insurance you currently have on record for my husband? He was just in earlier this month.”

“Oh, we have (current insurance company) listed as the primary insurance,” she says.

“Good. Can you tell me why the lab has (old insurance company’s) information and why they charged them instead of (correct insurance company)?”

“Oh, the new insurance information wouldn’t have been entered in the computer until the day after the appointment.”

I am rather shocked at this point. You see, I also used to work in a doctor’s office as a receptionist, and was responsible for collecting new insurance information from patients. “Um, I told you when I made this appointment for my husband that we had new insurance. Why did you submit this under the old insurance when you knew that it wasn’t valid anymore?”

“But, you see, it wasn’t in the computer, so that’s why it wasn’t submitted to the right company.”

“I get that. But why did you send it to the old insurance when we told you that we had new coverage?” I ask with gritted teeth.

“Ma’am, you don’t understand. It wasn’t entered in the computer until the next day,” she insists.

“I understand!” I practically bellow into the phone. “How did the lab get the old insurance company information to submit to? That’s what I want to know!”

“Oh, well, we print up all the lab slips for patients the day before they come in to have any lab work done, and we wouldn’t have had the new information then, because it wasn’t entered into the computer until the next day.”

I suppress the urge to let out a primal scream. How many messed-up billings do they commit in this office? It can’t be just me. I breathe slowly. Baby Boy is still nursing. “Okay, how does this get fixed?”

“Well, I can give you the number of the lab, and you can tell them that they submitted it to the wrong insurance company, so if you can just write this number down…” she says.

“Wait. A. Minute.” I bark. “You made the mistake in sending them the wrong information. It is really inconvenient for me to write down a number at the moment. So I think you should call them and fix this.”

“I’m not sure if I can do that,” she says, in a somewhat offended tone. “After all, you have all the patient information and –“


“Well, if it will make you happy, then I will call the lab,” she says, rather snottily.

“Yes. That would make me happy. Thank you. Good-bye.”

After I hung up and let out a frustrated sigh (couldn’t scream because now Baby Boy was asleep on my lap), I wondered, why did I say “thank you”??

So I called my mother, a medical bookkeeper herself, to complain. “It’s about (family clinic name),” I tell her.

“Oh, you too? I just called them to yell at them because they are trying to bill us instead of (state insurance) for Little Cousin, because (state insurance) is taking too long to process the claim. That’s a big no-no,” says Mom, who knows all the ins and outs of medical insurance billing.

I tell her my story, and she starts to laugh. “What?” I ask.

“It’s a good thing that we have different last names now and they don’t know that we’re related,” she snickers. “We’re an office’s worst nightmare – patients who know too much.”

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