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by Abigail Van Buren

DEAR ABBY: I'm writing in response to "Frustrated Doc, Utica, N.Y." who's looking for some explanation as to "why insurance companies employ people to handle claims in subjects about which they are not knowledgeable." As a fellow physician and medical director for Blue Cross and Blue Shield of Minnesota, our state's oldest and largest health plan, I believe I can offer some insight.

For starters, customer service representatives for health insurance companies do not make medical policy decisions; however, as the first point of contact for health-care consumers, they often answer questions about plan benefits. In addition, customer service representatives navigate what is often a complex health-care system. For this, they should be commended.

To address "Frustrated Doc's" concerns about who makes policy decisions for a health plan, let me briefly explain the process: At Blue Cross and Blue Shield of Minnesota, as is the case at many health plans across the country, decisions about what is covered or not covered are made by a panel of physicians and health-care experts. Decisions are based on solid, reliable, peer-reviewed, published medical research results.

Health plans are committed to paying for treatments that have been rigorously proven for their safety, efficacy and reliability. New treatments that have been tested only on a few patients at one academic institution shouldn't be covered until much more study is done. Fen/phen is a classic example of well-intentioned, but poorly researched medical therapy that, when unleashed prematurely, can have profoundly devastating effects.

If patients are not satisfied with decisions regarding specific treatments, I would encourage them to appeal the decisions through their health plans. Customer service representatives can provide information about the appeals process. -- JAMES WOODBURN, M.D., MEDICAL DIRECTOR, BLUE CROSS AND BLUE SHIELD OF MINNESOTA

DEAR DR. WOODBURN: Thank you for taking the time to address the concerns of "Frustrated Doc in Utica." Although I heard from many claims administrators, nurses and patients, you are the only insurance executive who responded to the question. Please read on for a slightly different perspective:

DEAR ABBY: May I comment on the letter from "Frustrated Doc"? As a pharmacist, I see the medical profession developing a new dimension -- generating reports and filling out insurance forms. Often attention is diverted to completion of a form. Believe me, there is nothing uniform in claims submission. Imagine 31 ways of submitting a claim for a prescription. (Or suturing a finger and completing a claims report.)

On Dec. 31, 1998, PCS (a prescription card) canceled all prescription coverage for federal employees for one day. I could fill a thick book with similar experiences.

Perhaps the next time your readers have a prescription filled, they will understand why the pharmacist has his attention centered on an insurance claim, or the reason you see six to 10 people in a doctor's office struggling with claims.

Members of the medical profession would be happy to spend their time working with patients and skip the insurance claims -- but we have families to feed.

If you can get this message to one insurance company or HMO, my time will have been justified in writing this. -- ARTHUR BOHLMANN, R.PH., HOOKER, OKLA.

DEAR ARTHUR: You have presented a compelling argument for standardized claim forms throughout the health-care industry. If they existed, what is now a tedious effort could be simplified -- saving many hours of duplicated effort, as well as the equivalent cost in dollars.

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