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  #1 (permalink)
: I work for an American Health insurance company, as a customer support representative. I feel like my job is based around ambiguities. The company has very ambiguous benefit structure. When I read the details to a health care provider, I know that it is coming across as very vague as to weather or not the plan will cover. The benefits are not specific and I feel like we are told to be vague with pre-certifications predetermination's, authorizations, allowable, medically necessity Ect. There is a paradox for the providers because they must bill with CPT codes or HCPC codes but coverage can not be determined by these codes. Exceptions for coverage is subject to interpretation.

Often the company will give us vague instructions, redundant verbatim; which places us in constant catch 22 situations. They force us to take the blame for the failure of their computer systems and software. For instance if I am dealing with a professional and my system freezes I am forbidden from blaming the system, I have to blame myself; however I am being subject to quality standards and satisfaction checks.

The company records every call, I know that this ambiguity is used to get out of paying as many claims as possible. I am worried because the calls are recorded, we are basically being used as scapegoats, can I be held liable, if my company wants to through me under the bus?

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  #2 (permalink)
: I'm afraid most companies have the same sort of criteria now it is disturbing to see, it's all about
confusing the customer to make money the more complicated it is the better off they are in the
end we will lose all trust in each other you are honest and can understand what you are doing
but what can you do the others are doing the same there are probably a lot more people in the same
situation but they have to work and make a living if you can't stand being a party to it find some
other employment at least your concience will be free.
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