It can be one of the most frustrating parts of the job,
speaking with the insurance company for your patient. There are times you just want to look at the
phone and wonder, what planet are these people from?
Insurers Goal
Keep in mind that behind the person you are conversing
with is under a team of executives pushing them to keep cost down. It may come across that the insurance
representative is being unreasonable, however you must consider their job
depends on their success in keeping those cost with reason.The insurance representative will have a
series of questions they will refer to, and depending on the answers, they may
insist that the patient can be cared for from home or a rehabilitation center.
The representative on the line with you has a goal, and
that is to cut cost. Insurance companies
are not out to harm patients; however, the fact is, sometimes their decisions
or lack thereof, does just that.
An Insured Patient
Mark was 45 years old when he was admitted to the
hospital. He had a severe stomach
infection and needed IV antibiotics for treatment. After treatment failed to produce results,
doctors brought up the idea that surgery may be necessary to remove a portion
of intestines that were infected. The process
at that point was to wait a few days and determine if antibiotics were
helping.
Two days later Mark was no worse, yet no better, so the
physician opted to wait, however the insurer was not in agreement. The insurance representative called the
hospital and spoke with Mark’s nurse to question why he was still
admitted. The nurse explained it was
currently a wait and see situation. The
insurance representative suggested that Mark return home while waiting, then
follow up with the surgeon or primary care provider. The nurse explained to Mark that she was
waiting for the doctor to call the insurer, and speak with a doctor there to
explain the situation in its entirety. Mark was frustrated with his insurance company, and said if they wanted
him to leave, he would just leave, which he did.
Four days later Mark was re-admitted in very bad
condition, and barely conscious. His infection had spread to his liver and
throughout his abdomen causing major problems. An emergency surgery removed some intestines, and a piece of his liver. At one point Mark was in critical condition,
and doctors were not sure he would make it. 9 weeks later Mark was able to leave the hospital, although with a
colposcopy bag attached. The attending
physician felt certain that if Mark had remained hospitalized the first time,
he would have been spared the much of the pain, and a lengthy hospital
stay. The insurer indicated they were
not provided all of the details concerning Marks condition. This is where proper documentation comes in, the
nurse did her job and documents exactly what she advised the insurance representative,
and the issue was resolved with no fault assigned, however the admission from
the insurer was lack of communication on their part.
As a nurse, when it comes to speaking with insurance
company representatives, make sure you have adequate training to do so.If you disagree strongly with the insurance
company, alert your supervisor and let them take the lead. Sometimes it takes having the patient’s
physician call and speaks with a physician of the insurers to help them better
understand the need for hospitalization.
With new health care laws health insurance has changed,
some for the better and some not. Many
patients worry if they do not comply with their insurers recommendations, they
may lose their health care coverage. One thing the new law does is to ensure the patient does not lose coverage;
they are protected under those guidelines.
The top priority is the patients’ health and care.In some cases, a hospital deducts a sizeable
amount from the medical bills in order to comply with limits set forth by the
insurance company. The goal is to bring
the patient back to good health, and you may need to resort to some creative
ways to work with insurers.
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