Navigating medical customer service – a reprise

The following was written a few years ago, but I thought I would repost this as it might help some. By the way, some of these suggestions might serve you well in other customer service experiences with banks, retail, supplies, etc.

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 you 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 condition.

– 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.

*Note: If you simply cannot pay hospital bill after the above gets resolved, hospitals have processes in place to request an abatement to some or all of the bill. Usually, a weblink or phone number on the bill can be found. The process is not too unwieldy, given its nature. Sometimes the answer is no, but it is not uncommon for them to cut something out of the bill. Given some of the numbers are multiple tens of thousands, anything helps.


20 thoughts on “Navigating medical customer service – a reprise

  1. Note to Readers: Due to a combination of complexity and bureaucracy, most hospitals are not the best of bill payers. So, issues arise between insurers and hospitals that may require your intervention. Even if you have medical coverage, these issues can crop up. For example, if your health care coverage is not codified in the hospital system, you may get charged the uninsured rate rather than a lesser negotiated rate with your HMO or PPO insurer. Top of mind, I am thinking of a difference of $15,000 on one such procedure.

  2. Having worked in the medical field both clinically and in administration for many years, I feel you are offering excellent advice. In so far as ones insurance paying for “everything”, this is not always the case. Insurance will generally pay for what is deemed medically necessary and as a rule they follow Medicare guidelines. Ones options are to request an appeal of the charges denied, as you state they will require records and a letter of medical necessity from ones provider of service. When all else fails it is often possible to negotiate the charges, or providing a letter requesting a write off due to hardship. Thank you for addressing this issue that has become more and more prominent during the pandemic.

      • Thanks. Forward thinking countries have national health care. It won’t happen in the US as the health care industry lobby is too powerful. So, we will go in on having the most expensive health care in the world with little to show for it.

  3. Thanks for the insight into the US medical system Keith. It would be interesting to read a dispassionate comparison with our NHS (Often referred by commentators as the nearest thing the secular UK has to a State Religion).
    “be as diplomatic and polite as you can, but sometimes it is hard”…Oh indeed that does open doors. It should also be born in mind by those on the other side of the conversation. In my latter years in the Civil Service, I sat next to colleagues with abrupt and dictatorial phone manners, and at the end of the day heard them complain about ‘what a terrible day they had had’. I sat there thinking ‘Have you heard yourself today?’

    • Thanks Roger. NHS are the way folks should go, but of course, no system is without its faults and things it could improve on. I would love to see us explore expanding Medicare to earlier retirement ages, such as age 60 or 62 (and evaluate the data at a future date to see if further expansion is warranted). To me, this would be natural way to extend coverage and improve cost models in the ACA and Medicare leaving younger patients in both.

      As to your last paragraph, one reaps what they sow. On the caller’s end, offending the helper is unwise. On the helper end, being uncivil is not very helpful. In either case, the outcome will fall short of what it could have been. Keith

      • Our NHS is not perfect; cause- lack of funding and a management fad of low level PR, with slogans, logos and smiley faces of senior managers….not really a thing uppermost in a patient’s mind- or staff for that matter…also spend money on management consultants who view things commercially….very bad move. Also too much pressure on staff to reach nebulous targets.
        I do not know a great deal about the US system, but it would make sense to give thought to the earlier retirement ages. Investing in the population at all ages is important.

  4. Pingback: #8 How to be a better patient – Should I get a second opinion? – Science, Cancer and Medicine

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