Case Study Two

When Things Get Complicated

The two primary purposes of owning health insurance is so people can have access to medical care when they need it and to prevent people from being financially wiped out in the event they do. Hopefully, you will never need to use your insurance or if you do, it is after a good long healthy life, but sometimes that is not the case. All too often we are witness to insureds who suffer severe traumas or chronic medical issues that are both physically and financially devastating. Our role is never more important than at that time and it is what truly separates the great agents from the mere transactional ones.

Over my career, I have helped dozens of clients who have had six or seven digit claims and we have seen everything from strokes, heart attacks, and cancer to motorcycle accidents, stabbings, and shootings. Every time we think we have seen everything, something new comes along. But no matter how great or small the matter is it is always associated with real people who are in a stressful situation and need an expert to guide them through the process.

It’s a Long Story

Recently, I met to do an annual review with a long time client of mine named Bob*. It was the first time I had seen him since he got out of the hospital. He was doing well but his nonchalance belied the seriousness of his bout with the health care system. He had gone into the ER room for a large painful kidney stone only to have it later become infected with sepsis. He is young and vigorous and made a full recovery but it is a good case study because he touched almost every aspect of the health care system. We have not seen the final bill yet but it is safe to say that it will be in the hundreds of thousands of dollars.

What makes this a good example is that it was a combination of both ER room billing followed up by acute inpatient care. So far there have been no ‘problems’ with either the hospital or the insurance carrier but the sheer number of providers involved was enormous. Any time a vital organ such as the kidney is impacted it means that many other specialists will get pulled in. Cardiologists, pulmonologists, urologists, etc. visited every shift and over a two week’s stay in intensive care added up. The laboratory work was extensive and around the clock, the medications used were very specific and tightly administered, and then there are the hospital charges. Bob pushed every button.

All’s Well That Ends Well

Fortunately, we have a dedicated person in our office to help with claims. Trish Hewison has worked with me for 15 years and handles internally the sort problems that ‘take more than 3 calls to resolve’. By having the right staff available, I can delegate matters that literally take months to resolve to a specific person so they can focus like a laser without interfering with the rest of the day to day operations that also need attention. It is much more efficient for everyone and prevents the client from getting passed back forth. They are happy and we are happy.

Working in our favor, we have an excellent relationship with our client and got involved early to make sure that everything went accordingly. When this happens, the first thing we do is to make sure the client’s policy is paid up and then we check the out-of-pocket maximum. After that we let the client know their exposure so they don’t have to worry about the money and then tell them to get well and let us know when the bills start coming in.

In the longer run, it can be months before the first bills arrive in and they will dribble in afterward (last year we had one bill that took 533 days to arrive!). Our standard operating procedure is for Trish to start a file, inform the client on what to look for and to send us their bills, and then keep them posted as to how much they owe and if something is problematic such as an out of network claim. This is the part of the journey where you never quite know where it will lead but it is very reassuring when a blizzard of surprise bills and EOBs come in. This case will take months before it can be considered final but things are under control and we follow it to the end. Thankfully, Bob is doing well.

*Most marketing gurus advise that it is always better to use real names and examples when doing case studies. While we agree with that in principle, most of our best examples we could give would reveal private financial, business, and medical information so we keep it anonymous.