Tuesday, July 10, 2007

Score another one for the system

In a June 28 post, I reported that my surgery, which is now just over a week away, was to be paid for by my health insurer at the in-network rate.
I was assured of this by the insurance company agent with whom I spoke.
It meant the difference between being more or less fully covered for the surgery, and being liable for thousands of dollars in costs before the insurance benefits kick in.

A woman in the billing department at my "home" hospital -- where I've been treated since first being diagnosed with parathyroid cancer in 2002 -- was skeptical.
Even though the surgery will be performed at another hospital, this woman, an angel if ever there was one, continues to stand by me and help me navigate the red tape.

"Get it in writing," she urged. She tried to do just that on my behalf, but was told flat-out by an agent that the company would not send her any documentation. She made further calls, none of which was returned.
She warned me that insurance companies will say one thing and then do another. They'll lead a patient to believe that coverage is provided in full, and then deny ever having promised that after the surgery is finished and it's time to pay the bill.

So I called the insurer to request in writing what they had assured me. I was more or less told that they never promised they would pay for the surgery at the in-network rate, and that it would be treated as an out-of-network procedure.
In order for it to be considered otherwise, they said, the surgeon performing the procedure must contact the insurer and prove that he is the only surgeon within a 70-mile radius qualified to perform it. And then, the surgeon must request payment at the in-network rate.

Great, I thought, I'll just call the surgeon and ask him to provide this proof of qualification. But I was told by his office that the hospital forbids its surgeons to enter into payment arrangements with insurers. This must be done by the hospital itself.
And the likelihood of them doing so is very slim.

So, I'm not exactly back at Square One -- the surgery is, after all, approved by the insurer, and will be given limited coverage -- but the costs just got a whole lot higher.

This experience proves what my benefactor at the other hospital and what those in similar medical straits have told me:
The insurance companies lie -- or at least make things gray enough so that you're unsure exactly what it is they're promising (or not). I learned this when I requested their assurances in writing.
Insurers evidently count on a certain percentage of patients becoming so frustrated with the red tape that they give up their fight (or die before claims can be resolved).

I'm lucky, in that I have sufficient command of the language to state my case and argue with those who would thwart me.
Plus, I'm blessed to have many people who fight on my behalf and whose help has been inestimable as I navigate these rough waters.
And I have a job. Eventually, the bills will be paid.
But what about a person who doesn't have these resources? What about the elderly, who often lack family or friends to advocate for them? What about the uninsured, underinsured or unemployed?

A few people have asked me if I've seen (or intend to see) Michael Moore's new film, "Sicko," which documents the abuses of the health-care system.
Why the hell would I want to see it?
What is Moore going to tell me what I haven't already learned through my own experience?


Jean said...

I'm so sorry to hear this, and very glad you have health-care professionals who are on your side.

Michael said...

Thanks, Jean.

Compared with the experiences of others, mine is hardly a horror story. It's more a case of same shit, different day.

It points out the sorry state of the health-care system in this country, however. Based on my limited knowledge of the situation, I would say that no country has the ideal approach to the issue. But it seems to me that the U.S. does a pretty poor job of addressing the problems.

east village idiot said...

F*ck those motherf*ckers!

Maybe we should start taping our phone conversations to hmo's to ensure "quality standards" on our side of the friggin fense. Seriously, we should start taping our phone calls. It makes my blood boil.

Thank God you have a job and a loving family around you now. And yes, how those less fortunate than you must suffer at the hands of these jerks.

But what is most important is for you to have your procedure done by someone you trust. You have that person. Let's focus on that right now. You're in good hands. We'll fight the good fight after you recuperate.

And as for Sicko. Of course you shouldn't see that. You need to spend the next ten days editing unwanted crap out of you line of vision including your heart's vision. Shut off the news, take care of yourself, and meditate if possible.

Michael said...

Yeah, it's frustrating. It's getting like banging my head against a wall sometimes, but I think I'll prevail.

I don't want to comment too much more about this right this moment, though, because I have a related post that I want to put up Wednesday.

It gets more bizarre...

EdaMommy said...

I can totally commiserate. Right now I'm trying to get my insurance company to explain to me why the only ambulance carrier in the area is "out-of-network" when it comes to transporting my 5 year old from one hospital to another. Nothing like being told that, after a $20,000 hospital bill, that the ambulance bill has been applied to my deductible?!?! They are definitely slippery. Best of luck to you.

Michael said...

Thank you! It seems nearly everyone has at least one horror story about dealing with health insurance companies.

Mungo said...

Good luck with your surgery - I wish you well.
All the best,

Michael said...

Thanks, Mungo. I think everything'll work out fine.