Kevin Standlee (kevin_standlee) wrote,
Kevin Standlee
kevin_standlee

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A Vision of Insurance

From 1987 to 1993, I worked for Blue Shield of California, first as a claims data entry operator and then through a series of progressively more responsible claims review areas, then as a systems analyst and technical writer after graduating from CSU Chico. Because of this, I have some familiarity with insurance and medical terminology. I'm also sympathetic to the people who work in this field, such as the customer service rep to whom I spoke today about an insurance claim.

As I mentioned in a previous entry, I had an eye exam last month prior to being fitted with new glasses, during which the doctor removed a small bit of something that had been paining my eye for about a week or so. This week, I received the EOB (explanation of benefits) from my company's medical insurance carrier, and I was not pleased.

I have a $250 vision benefit payable once every two calendar years. That $250 is supposed to cover the eye exam and glasses. That's a pretty bogus amount and hasn't changed in the ten years I've worked here, but never mind about that now. The point is that I have to make the $250 stretch as far as I can.

Because my eye doctor only provided a diagnosis of "eyeglass fitting," my examination with her fell completely under the Vision Care benefit. That's not right. At least half of the examination was medical in nature, having to do with diagnosis and treatment for the pain in my eye and removal of the whatever-it-was. If there's a medical diagnosis on the claim, they'll pay at least part of it on the ordinary medical benefit and leave me some of the vision care benefit to go toward the glasses. (The $250 still won't cover both the exam and glasses, but I'm trying to get as much covered under medical as possible.)

So I called my company's insurance carrier and eventually managed to break through menus and voicemail to talk to a person. She explained that I need the provider to re-submit the claim with a medical diagnosis. I then called Camino Medical Group, and after explaining the situation a couple of times, found someone who said, "I'll order your chart and see about re-submitting the claim." In the meantime, the woman at the insurance carrier suggested I not cash the insurance payment yet (they pay vision care claims directly to me, not the provider) because if they get a resubmitted claim, the first thing they'll want to do is reclaim the earlier payment. Even though eventually I would end up with the same amount of money, I understand why they would want to do this.

So eventually this should be straightened out and more of the cost of my glasses should be covered by insurance. I'm just glad I put money into a Flexible Spending Account so that I didn't have to front the money for the glasses.

Follow-Up: Dr. Fong called me later this afternoon and said she'd be happy to add the additional diagnosis, which she'd written on the chart anyway but which had apparently not been transferred into the billing system. She's been a pretty good optometrist. She even remembers that science fiction conventions are my hobby, which I reckon is pretty good for a patient you only see once ever two years.
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