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Thursday, October 08, 2009

Can we talk about Health INSURANCE Reform?

In addition to the usual 'sturm und drang' of life in the fast lane of Parish Ministry, I've been doing battle, of late, with my Insurance Company.

You know, we don't need Health CARE Reform as much as a complete overhaul of the Insurance Industry.

Health Insurance is a good place to start.

I'm going to have some minor outpatient surgery next week. Nothing too complicated. Nothing to worry or stress about. I've got an excellent doctor I've been seeing for the past six years.

He's brilliant and well-educated as well as being kind and compassionate. He takes time to talk with me, not only explaining things, but making sure I understand what he's saying. We've developed a good, trusting relationship over the years.

I trust him completely.

The medical system he works in also has an outpatient day surgical center. Because of the size of the practice, they can negotiate better prices with insurance companies, which pass down the savings all around.

So far, so good, right? Wrong.

I thought to call his office the other day, just to make sure everything was in order and that my insurance company had authorized the surgery (I'm like that. I love surprises but I'm not very fond of the kind you get when you're signing in on the day of surgery at 6:30 AM - on a stomach empty of food or coffee.)

"Hmmm," said the insurance coordinator, "It says, 'no authorization required' so I guess you're okay."

"Wait," I said, my gut lurching intuitively at bureaucratic language, "What does that mean - 'no authorization required'? Why doesn't it just say, 'approved'?"

"Hmmm . . .," she said appreciatively, "You know, I don't know. Let me connect you with the guy in our pre-certification office. He's a good guy. He'll be able to 'translate' for you."

A couple of clicks and more than I wanted to hear of 'musak' later and I was on the phone with the guy from pre-certification. I told him my story and asked if he could translate.

"Hmmmm. . .," he said, "I see your point. You know," he said, "I would strongly advise you to call your Insurance Company and ask them."

So, armed with a few diagnostic and procedure codes, along with my health insurance card with my group and individual numbers, I bravely dialed the toll-free number for Member Service thinking this would be a simple conversation.

Question asked and answered, right? Wrong, again.

Never mind that I called twice in an hour and a half, only to hear that there were no 'membership representatives' available due to a training session. I got "Marie" on the third try.

Ah, Marie.

I can only imagine Marie as an inexperienced young woman whose defense against her own sense of incompetence was to project it on to others. Attitude? Our Marie had tons of it.

I carefully explained my situation to Marie who was having difficulty getting her computer to respond quickly enough. "The system has been slow all day," she said from behind teeth that were obviously clenched.

Everything she said was prefaced by, "Let me see what it says here . . .ah, here it is . . ."

Not exactly a boost to one's confidence, you know?

So, here's the bottom line: I didn't need authorization for the procedure BUT - (and here's the important part) - because the procedure was NOT being done in hospital AND because I didn't have a referral on file, it would be assigned "out of network status."

"Oh," I asked, innocently enough, "what does that mean?"

Ready? Well, if it were IN NETWORK (i.e., if I had had a referral from my primary care physician), I would be responsible for a $200 deductible, which I had already met, this being October and all.

BUT, since it was OUT OF NETWORK (i.e, because I didn't have a referral from my primary care physician), I would be responsible for a $500 deductible (which I hadn't met because I had never gone out of network all year), PLUS 30% of the total cost of the procedure.

"Wait, WHAT?" I asked incredulously. "Why do I need a referral? I've been seeing this guy for 6 years? It's not like he's new."

"Well, let me see what it says here . . . .ah, here it is . . . you are required to have a referral on file once a year. So, since you don't have one, you'll be responsible for the $500 plus 30% of the total cost of the procedure."

"Wait, wait, wait," I said, "So, if I call my primary care physician today and have someone in his office enter it into the system (their offices are in the same building), and we get it to you tomorrow, I will have no out of pocket costs, right?"

"Well, let me see what it says here . . . .ah, here it is . . .yes, that's right."

"So," I asked, trying to stay calm, "why did it say 'no authorization required' when it should have said, 'referral required'"?

"Well," said Our Marie, full of attitude, "it's a requirement of your policy. It's YOUR responsibility to read your policy and comply with it."

I took a deep breath and decided not to say, "Listen you little snot . . .," but rather, "Yes, I understand my responsibility, but you know, I don't have it in front of me on a computer screen. And, when I checked my manual, there wasn't anything that said anything like that."

"Well," she said, "the manual is updated online and it's YOUR responsibility to check the updates." (I can't effectively communicate the attitude with which this was said.)

Her 'tone' reminded me of my third grade teacher, Mrs. Muggleton, who, I trust, has now worked her way out of a few years of purgatory for her sins and rests in Light Eternal. No one could shame and blame like Mrs. Muggleton. Except, of course, for Our Ms. Marie.

I cleared my throat and said, "And, how exactly is it that I would know that the manual has been updated? I mean, I'm not aware of having gotten any notices in the mail or via email that there had been such a significant policy change."

Again, she said, "Well, it's still YOUR responsibility to check before having any procedure done."

"Okay," I said, "aside from the fact that I was obviously remiss and no doubt irresponsible in reading my policy manual, may I still ask you a question?"

"Sure," she said, smug and secure in her superiority.

"You are in member services, right?"

"Yes," she said. I could see her polishing her name tag.

"So, how does this serve me, the member?"

"Excuse me?" she asked. I could imagine her scrolling furiously to find the category for this question in her online 'membership' manual.

"I mean," I said, "if the response to my doctor's office had been 'referral necessary' instead of 'no authorization required', I would have been able to make a single phone call, get the referral, and it would have saved me, perhaps, thousands of dollars."

And she said - I kid you not - ""Well, let me see what it says here . . . . (scrolling, scrolling, scrolling) . .ah, here it is . . .(reading, reading, reading) yes, that's right."

"So, my question again is: How does this serve me, the member?"

I had thrown her another curve ball. Our Marie was NOT pleased. "Excuse me?" she asked, in a mixture of confusion and indignation.

"Let me break it down for you," I said, my last, poor tired nerve having been pulled. "Whether I get the referral or not, the insurance company gets paid and so does the doctor. Right?"

"Right," she said with a tone of caution.

"So, bottom line, the one who ends up paying more is me. The member. The one you are serving. Right?"

Scrolling, scrolling, scrolling.

"Well," she said, "it's YOUR responsibility to get the referral."

"I accept that," I said, now through my own grit teeth. Sheesh! "But how would I have known that was necessary from 'no authorization required'?"

"Well, let me see what it says here . . . ."

"Wait! Stop!" I said, finally and completely exasperated, "I know, I know. It's MY responsibility. But, YOUR responsibility is SERVICE. To MEMBERS. That would be ME. MOI. How does 'no authorization required' serve ME - the MEMBER - if I end up paying out of pocket when I don't need to? When all I have to do is make one phone call for a bloody referral?"

Believe it or not, it went down from there. I asked to speak to her supervisor. She said one was not available.

I asked to file a complaint. She said she'd put a form in the mail. When I asked her when I would get it, she said, "in about 30 days."

I asked if there was a complaint form available online. She said there was. I asked her for the link. She said she didn't have it. I said I would look for it myself.

Then Our Marie had the unmitigated gall to ask, cheerily, if there was anything else she could help me with today.

I hung up on her. I know that was rude, but I feared what might come out of my mouth would be something quite surpassing rude.

I went online. I filled in a complaint form. Someone called me this morning. A lovely young woman who not only got it immediately but was greatly distressed by my story and promised to get back to me with a response before the end of the business day.

Meanwhile, I called my primary physician's office. Sure, they said. No problem. We'll send a referral downstairs to your specialist's office. It should all be taken care of, but do check in again on Friday with your insurance company. Just to be sure.

Her supervisor called me this afternoon. Nice young man. Knowledgeable. Competent. He and I talked. He never once referred to a computer screen, even though it was clear he was checking for information about my policy and what was covered and what was not.

He assured me that all I needed to do was get the referral. Promised to call me as soon as my doctor sent it over to them.

He not only understood the problem and acted on it, he also promised to:

1. Request an adaptation of the form from the IT department so that it could distinguish, 'referral needed' vs. 'no authorization required.'

2. Make sure the online and print policy manual had the stipulation of an annual referral from one's primary care physician to a specialist written in bold and obvious to the 'member'.

3. Contact me once those changes had been made.

Sweet Baby Jesus and all the angels that rock Him to sleep at night!

If a body doesn't need health care before dealing with insurance companies, you surely need one AFTER.

I'm convinced that it's not Health Care, per se, that needs to be 'reformed'. It's the Health Insurance Industry, who are, essentially, practicing medicine without a license.

I'm going to make another phone call to all involved parties on Friday, just to make certain that all the 't's' are crossed and the 'i's' dotted, get the approval codes from the insurance company and write them down in my calendar so I can bring them with me when I have the surgery next week.

And, I'm going to pray for Marie. I suspect, unless she learns to reign in that attitude, she'll soon be out of a job.

I'll feel bad about that, but you know, ultimately, it's HER responsibility.


Fran said...

Holy sweet Mary Mother of God! What a story.

And thank God you made that call.

This story makes me think of so many things...

One of the first is that all who cry "communist!" and "socialist!" are nuts. The phone call and system you describe sound like what we were taught about the bureaucratic evils of trying to buy one item at the GUM department store in Moscow, circa 1965.

Second - I am reminded of people who simply might not have the time or the where-with-all to make that call and to find this out beforehand.

Third - the mechanism of and mechanics of the for profit insurance industry are institutionalized evil if I ever saw it.

Not to make excuses for Marie, but she is probably paid poorly, trained poorly and will be receive financial incentives from treating people as she treated you. The person you spoke to later may just be the "good cop."

I hate to be so cynical, but this whole situation does rather inspire it.

Prayers for you and your outpatient surgery!

Elizabeth Kaeton said...

Hey, Fran, those same questions occurred to me, too, but I didn't want to sound so cynical, but I'm afraid the whole scam of the Health Care Insurance Industry has made me a cynic. Bad cop - good cop is as old as the Story in The Garden.

Thanks for your prayers. I cherish them.

Kay & Sarah said...

What a mess! And thousands of people face this every day! The health insurance companies have ruined health care in our country. Fran is right the employees in the health care industry make medical decisions for the doctors and nurses and we have let them get away with it.

In addition to calling your insurance company, you may want to call or write your representative and senator.

Praying for that things go well for you.

Kay & Sarah said...

Another example of how the health insurance industry treats its clients:

Unknown said...

I work in the insurance business. First, health insurance is complicated, second, the rep on the phone did a horrible job of explaining your policy to you. Here's how I see it: referrals are involved in managed health plans, which you must have. you should always have in the back of your mind that you may need to request a referral if you are seeing anyone besides your primary care doctor. secondly, no authorization can mean a couple of things, but in your case it meant that your procedure was considered standard, as opposed to possibly not medically necessary (like a breast reduction - which can be done for medical or for cosmetic purposes). so, the procedure was automatically authorized, but because you didn't have a referral, it was authorized at the different payment level than if you had had a referral. bottom line, i encourage everyone to call and ask, even if your walking across the hall for an xray, that could require a new referral or authorization, or any number of other things. sorry it's weird. get the name of a good customer service rep at your insurer and her extension and use it.

Unknown said...

fran, you are correct that this is a horrible process for people who do not understand their insurance contract, just like folks everywhere have trouble with all sorts of contracts, but as a member of the evil health care industry, i can assure you that i am: very well educated, very well trained, and consider it my vocation to help each and every one of my customers to effectively navigate this big system and also to assure that my company pays each claim that they should as required under the contract, and not just pay it, but pay it happily, as quickly as possible. let's not paint with too broad a stroke.

Kirkepiscatoid said...

So...uh...what's your deductible on psychiatric services? After dealing with Marie, I imagine you might need 'em.

If it's any consolation, they hate the providers just as much. I once spent 45 minutes on the phone with (hack, cough) harummphhhhUnitedHealthCarehackcoughhrrrph going stark raving bonkers on a patient advocacy mission.

The patient, who had an enlarged lymph node and two people in the family with malignant lymphoma, got denied the $1200 worth of special stains for lymphoma markers I did on his lymph node biopsy. I did not see any evidence of lymphoma under the microscope, but I did not want to take the chance an early population of lymphoma cells were brewing in there. He had this node come up all at once and was having night sweats.

The rep cheerfully told me that if the patient had actually HAD lymphoma, they would have paid, but since he DIDN'T have lymphoma, the special stains were "medically unneccessary."

That was a double whammy. Patient didn't get covered, and I get a tic in the "doctor who orders medically unnecessary tests" block. Only after three different supervisors and the medical director did the patient (and I) get justice.

VTcrone said...

As you know, I am a retired RN. At one point in my career I worked for a large insurance company in the health insurance side of things. This company no longer sells health insurance. My husband is a retired VP of Accounts from the same company.
Over the years, there have been several occasions where we have had to go toe-to-toe with whatever health insurance company we were covered under at the time because of the way things were worded in the contact, as one example. In our case, there were 2 of us, who were familiar with insurance plans, working together to figure things out but it is very confusing and often folks are given the wrong information. (Your story is a perfect example of that.) I worked as a private duty nurse in home care toward the end of my career and if a client told me that they were having difficulty with their insurance company, I would say, "Write a complaint to either the CEO of the insurance company or the state insurance department. These complaints always bring a quick response."

Here's a link to Keith Olbermann's special comment on health insurance and what's going on right now. (His dad has been in the hospital for a while now.)If you just want to read the text of his comments, they are on the Huffington Post.