Your HMO Thinks You Are a Crook: Prepare to Be Investigated
Today I learned of a policy my insurance company, Tufts, has in regards to orthopedic injuries. I received a letter in the mail from Tufts, stating that they had hired the Rawlings Company LLC, to make sure the injury to my finger was not caused by an accident. If it had been caused by an accident, Tufts was not the party to pay the bill. I read the letter many times because I couldn't figure out what it was about. Back in July, I had injured my left middle finger changing the linen on my bed. I had gotten it stuck and when I pulled it out, I had torn the tendon in the end of my finger and it was hanging loosely. I went to the doctor, diagnosed with "trigger finger" and was sent to the orthopedic doctor. I was told I needed to do six weeks in a splint so off to occupational therapy to get the splint.
Next, I get the letter and at first I think this is a scam. So I call Tufts and was told yes Tufts uses Rawlings to investigate if the client "mistakenly" got reimbursed from another policy if it was an accident. Essentially, I was being investigated to find out if I had double dipped (their words) and gotten reimbursed and not told them. Well, I have to say, my blood pressure went up and my voice got very annoyed. Here's the conversation abbreviated:
I wanted to know why no one from Tufts had called me when the first diagnostic code for trigger finger was filed? Answer: It is standard procedure for this diagnostic code.
My question again, why didn't my insurance call me first and not treat me like I was lying?
Answer: Tufts needs to make sure they aren't loosing money.
Do you think I lied to Tufts?
Answer: Oh no, Tufts does not think you would lie but maybe didn't understand other insurance would cover this.
Did you pay the doctor yet?
Answer: Oh yes all the bills have been paid.
How could you pay if you thought another insurance was involved?
Answer: it is standard policy.
Can you clear me now?
Answer: Oh no you have to call Rawlings.
Here's what I think. They presumed I was lying. I then had to justify myself to an investigative company, a wing of TRW which is a major investigation company with deep pockets and resources. There is nothing in my policy stating this was a service that would investigate me. Nor was I informed during the last eleven weeks there was a need for information. I would have gladly given it to them. They also could have contacted my primary care or the orthopedic doctor because if I had filed with another company like home owners, they would have had to send medical records related to the accident. What I see is a way for the insurance company to figure out a way to drop clients. If I hadn't called I would have given Tufts a reason to drop me . For many people, this letter could be very confusing or frightening. It appears phony. No matter how Tufts wants to spin this, it is deceitful and disgraceful. Any reasonable person would conclude, the business of the HMOs is not health insurance. There business is solely making a profit. In the same way that cigarettes came to be known in the tobacco industry as "nicotine delivery devices", it is clear that the health insurance consumer is nothing more than "the profit delivery device " for these huge corporations. Here is what I plan to do. File a grievance with Tufts, a complaint with the Division of Insurance and the State Attorney General's office. There is something unethical about the manner in which Tufts went about this.
Posted by HealthCare Whisperer at 9/29/2009 1:47 PM 
Categories: insuranceHMO, claims, accident
Tags: insurance HMO claims
Categories: insuranceHMO, claims, accident
Tags: insurance HMO claims
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