Communication with Insurers 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. Related: Obsessive Compulsive Disorder Facts 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. Related: Top 10 Reasons to Become a Preceptor 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. Related: Expert Geriatrics Nurse Marie A. Bissell, APRN, GNP-BC, will be Spotlighted in the Worldwide Leaders in Healthcare Please follow us on Facebook, Linkedin, Pinterest and Twitter