Robert Stein 1924-2014

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Tuesday, October 22, 2013

The Coming Obamacare Claims Crisis

Amid all the hubbub about ACA website failures and Obamacare squabbles, completely overlooked is a massive new problem faced by health insurers who will not only have to manage millions of new customers but actually start paying some of their claims.

Their plight may be masked by all those premiums they will collect, but how will they cope with an actual outflow of cash?

As a public service in their hour of need, I am resurrecting herewith a classic memo on how they have avoided such damage to their profits in the past that will have to be slightly revised to deal with the annoying provisions of Obamacare:

“TO: Claims Prevention Department

FROM: President, HMO

Bills are being processed and paid without full use of our avoidance procedures. Since 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. 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 results in the future. Remember: A claim denied or delayed is a drop of lifeblood to the health of our organization.”

Some heartless observers may scoff at the pain being inflicted on such hard-working organizations but, for those who sympathize with them, there is some consolation. Think of their chaos if those Washington radicals had passed a law for a single-payer system or Medicare-for-All!

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