Navigating medical customer service

Before I share a few observations and experiences, let me first note that too many Customer Service Representatives (CSRs) are likely understaffed and undertrained to do the jobs they are asked to do. The healthcare system in the US is complex with a lot of moving parts, including consolidated entities on the provider side and insurer side. In other words, there are plenty of opportunities for the system to fail the customer, provider and insurer.

Through all of this, the patient has to be the navigator of his or her customer service experience. Otherwise, the patients may not realize they are not being treated fairly. As evidence that I am not personalizing this more than I am, let me mention two things.

First, I have a friend who runs a successful business advocating for insured patients. Her firm is hired by companies to help their employees and retirees navigate the healthcare insurance system. In essence, they advocate to get the insurers to pay for what they say they will in plan documents. No more, no less.

Second, as a retired benefits manager and consultant, I am familiar with the complexities, but there are people who know them far better than I. So, what concerns me is people who get maltreated  by the system and don’t know they can push back or don’t feel comfortable in so doing. The various acronyms, footnotes, poor communications, entities and touch points are confusing.

Rather than lament issues, let me offer a few tips to help in the navigation.

– If you need a pre-authorization for a surgery or procedure, start at least a week before or as soon as you can. Ask what they need and make sure they know who to call. An increasing number of providers are putting the burden more on patients to get the process started.

– On any call or reach-out, save emails or notifications, write down notes, names, dates and phone numbers – there are many, especially with centralized functions for smaller doctor offices. Recently, I was given multiple numbers to call (and addresses) from each party.

– Read your EOBs – Explanation of Benefits – including the footnotes as to why something was unpaid or pending. There may be an action needed on your part. If have a non-ACA, non-Medicare or non-employer plan, there may be a need for medical information to confirm this is not a pre-existing conditon.

– If you feel uncomfortable with asking questions of your doctor or insurer, write the questions down or include someone to advocate for you. Don’t be afraid to ask what someone said as it can be confusing or the person may not be the best communicator. And, if it is a major surgery or procedure, it is more than OK to seek a second-opinion.

– Follow-up. This is critical. Hand-offs are made to do things and the receiving entity may not confirm it has the ball. As a result, while you are waiting, nothing is happening. If medical records need to be there in 30 or 60 days, follow-up 10 – 15 days before those deadlines.

– Finally, be as diplomatic and polite as you can, but sometimes it is hard. So, be prepared to say something like, “I am sorry to be a pain, but this is frustrating.” Also, if urgency is needed, please share that need. Some readlng this may note there are websites to facilitate this process, but too often, the website does not do what you think it is doing. It may just be recording a query and not codifying an action. You may be surprised how frequentIy I have to read to the CSR what another part of the company sent me.

Again, there are many fine people in these positions who want to get things right for the patient. It is often said, good people make up for a bad structure.  Yet, it should not be as hard as it is. Until it is made easier, you must be the navigator of your customer service.

Please feel free to share your ideas and reactions.


11 thoughts on “Navigating medical customer service

  1. Note to Readers: Please use the appeal process if you feel like your circumstances warrant a payment. Let’s say you are allergic to the generic version of a drug, but not the brand name due to some coating, lack of costong, etc. You can appeal to get the brand name dispensed as a formulary or at a lesser price. Mind you, it does take effort, but it could mean the difference between $1,500 and $75.

  2. Valuable post Keith for any one in contact with the public, particularly in the labyrinth of your health service insurance.

      • The odious Farage wants to replace our NHS with an insurance based arrangement.
        If it came to a stand off between him and the equally unpleasant Boris Johnson, if Johnson supported the NHS I would do the once unthinkable and support Johnson…on this matter.
        We live in troubling times Keith

      • Roger, no system is perfect and could always be made better, but doing away with a national health insurance is an unwise idea. When the ACA was announced back in 2010, I told a colleague then, what we need is a national health care system in the US, but it will never happen due to the healthcare-industrial complex. Yet, we should expand Medicare lowering retirement age, which actually works pretty well relative to other approaches.

        While I would hate to see the train wreck for the UK, it would be poetic justice for Johnson and Farage to have to deal with the huge problems of a no deal Brexit. Keith

  3. Excellent advice, Keith. I have gone through the labyrinth a few times and my modus operandi now is to avoid doctors at all costs! Health care in the U.S. is an unnavigable maze that nobody should have to contend with, especially when they are already unwell!

    • Jill, staying out of hospitals and doctors offices is a good strategy, provided you remain well and take care of your health. I had two elongated CSR experiences, one for me and one for my wife, that I had tried to head off long before they became crisis. Keith

      • In this, the day when private equity groups are hungrily buying up doctors offices, clinics, labs, etc., I look for the situation to get even worse. Even daughter Chris, an RN, agrees that health care has become much more about money than patients. Sigh.

      • Jill, true. When private equity buys a firm, often the focus is more short term (since they may turn the investment in five years or so). So, customer service and relationships are diminished in importance. Keith

      • Very much so. The one that is buying the practice my daughter works for plans to put in place some policies that have nothing to do with good patient care, such as limiting the amount of time a doc can spend with the patient, and refusing to see patients who have no insurance and cannot pay up front. It is no longer medical CARE, but rather just another business.

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