H.M.O.'s Secret of Success

Health care coverage is shaping up as the hot-button domestic issue for ’08. To help Presidential candidates of both parties understand what they are up against, herewith a confidential memo provided by a public-spirited insurance company insider:

TO: Claims Prevention Department

FROM: President, H.M.O

Bills are being processed and paid without full use of our avoidance procedures. Such negligence impacts your company’s bottom line, let me review our guidelines:

1. Use the response “require more information from physician” to its full extent. Some providers fill in code numbers, diagnoses and dates of treatment. But who are these people? Can we trust them with the health of our insured not knowing when and where they went to medical school, how long they have been practicing, and whether they rent or own their Lexuses?

2. Handle phone queries properly. Quick answers deprive members of full participation in their care. For the persistent, employ your half-hour hold capability and, if that fails, tell them the computer is down and promise to call back. That will keep them close to their phones and away from doctors’ offices.

3. Don’t confuse claimants with data overload. Just indicate service is not covered because of a,b,c,d,z or some combination. Our forms make definitions of a,b,c,d,z easily comprehensible with the aid of a magnifying glass and legal dictionary.

4. Use “pre-existing condition” as a disqualification. If enrollees are treated for back pain or headaches, assume they had backs and heads before signing up. Are we to pay for problems that should have been treated in the past?

5. When all else fails, deny reimbursement with “This claim has been previously considered.” By the time the patient, physician, laboratory and hospital check with one another, no one will be sure who sent or received what. We should not pay twice or, better yet, once.

We will soon have new tools to aid in your work. A revised schedule of “customary fees” will reflect the global economy by factoring in provider charges of emerging nations. And our accountants are number-crunching the promising concept of a receding deductible.

Our new non-discriminatory policy of hiring applicants regardless of IQ, education or Attention Deficit Disorder will insure better performance in the future. Remember: A claim denied or delayed is a drop of lifeblood to the health of our organization.