The abridged version (if possible)…
Last Thursday, I received a $115 bill for lab work done in July 06. My reaction – wtf? So I called the lab, ascertained this was because a UTI. My comment to the lab lady was “Let me call my insurance company. I suspect they screwed up, which they’re very, very good at.”
First stop – website. I looked up the EOB (explanation of benefits), which contained FOUR charges from the lab totalling $180 (negotiated down to the $115 bill I was pummeled with). For a urine culture? Again – WTF?! The reason they hadn’t paid for this charge was some mysterious “in-network medical deductible”. First time I’ve seen this.
Then there was the charge from my physician, $30 office visit plus a $20 lab test (where they stick the litmus paper in your urine and say “Yes, there is bacteria. Have some anti-biotics!”) I never actually saw my doctor at the time, I just peed in a cup and dropped it off at the front desk. I had been arguing with my insurance company about the proper reimbusement for my allergy shots at the time (and one idiot at the insurance company said that even though I was in the allergist office for five minutes and only saw the nurse who stuck me in either arm, I had to fork over an office co-pay each week ON TOP OF the price of the shots, which they didn’t want to pay for either. Obvious bullshit), so when the receptionist asked me if I had a co-pay, I replied in a weary voice, “I really have no idea.”
My office visit co-pays are $25. According to some calculus the insurance company did, they expected me to be responsible for $20.63. This number defies all logic.
So I put in a phone call to my doctor’s billing person to discern what in the HELL could require nearly $200 work of lab work on my urine. She’s unavailable so I wait for her to return my call.
Understand how employer sponsored healthcare works. Your employer writes the policy. Your employer is the one who decides what gets covered and what doesn’t. Your EMPLOYER is the idiot who thinks nitrous oxide isn’t necessary when you have major dental procedures. Your employer then hands it over to a publically-traded insurance company to manage. They handle all questions, billing, reimbursement and the like. The only portion of the policy the insurance company actually controls is the pharmaceutical formulary. Otherwise, blame your EMPLOYER for suck-ass insurance.
So I call the insurance company. I despise these people for the simple reason that they manage a million different plans, your call goes to a phone bank (after you traverse the damned phone tree) so you have someone different to deal with everytime you call, and they know nothing but what they read on the screen. They’re experts at getting it wrong.
The result? This woman gave me some lame convoluted story about the $20.63 (That’s their other genius – defending their erroneous information. With this skill, they should just all become politicians). I even said, “What if I would’ve paid my $25 co-pay like usual?” She actually had the audacity to say, “The doctor would’ve reimbursed you….”
As if a doctor will EVER reimburse you anything. When elephants fly.
She then tells me I’ve had this “deductible” since January 04. I ask her specifically what it covers. She says, “Anything that isn’t an office visit, because you have co-pays for that.” Good grief.
I scour through two years of EOB’s looking for this ellusive “deductible” and what it supposedly applies to. Not surprisingly, the result is a cluster fuck.
The following day……
I converse with my doctor’s office. She tells me they asked for a urine culture and sensitivity wherein the lab tested for the specific type of bacteria I was plagued with. She has no idea how that’s billed.
So I call the lab. I ask for details on the tests performed.
The woman says “We’re just billing…”
I ask, “Who do I need to talk to?”
She replies, “Well nobody, The Privacy Act…You need to call your doctor.”
I thought my head would explode.
“I already talked to my doctor. They don’t bill me you do.”
“Yes, and there are charges here for….”
“I can READ. I know what I was charged. I want to know what tests were done and why.”
“I can’t tell you that. The Privacy Act…”
“But I’m asking about MY records.”
“Well anyone can call and say they’re you.”
(I’ll ignore the fact that I’ve been talking to your company for however many minutes, just as I did yesterday and no one seemed particularly concerned about my identity then!)
“What information do I need to send you to confirm my identity?” I ask, still attempting to solve the problem.
“You can’t. The Privacy Act….”
I pause. I breathe.
“You mean to tell me the President can tap my phone but you can’t tell me the tests that were run on my urine when you expect me to pay $115 for them?!”
Long pause in which this woman was probably contemplating a new line of work.
I say, “Do you see the irony in this?”
“Yes, I do.”
“Un-fucking-believable” I mutter and hang up the phone.
I call my doctor’s office again. Flip out at the billing person. She handles me beautifully. I really should send her cookies.
I call the lab a third time. Get yet a different person. (yes, let’s hear it for the phone bank). I request details on a urine culture and sensitivity. I explain all I have is a bill. “No invoice?” she asks. Nope. She then offers put the detailed invoice in the mail for me on Monday. Thank you very much, Billing Lady, could you walk into the next cubicle and kick the bitch I just spoke with in the shins?
My next stop is the employer benefits department. Oh yes, I want to know about this deductible. Last time I called them with a question, the first comment I received was “Did you call the insurance company?” Through gritted teeth, I replied, “Yes, four times. As did the office manager of my allergist. We get different answers every time. I need you to tell me the policy.”
So I’m not exactly optimistic about this call.
I explain the situation. She says the deductible covers the FIRST three hundred of your medical expenses every year. EVERYTHING. I relate what the insurance company said (everything but office visits). She concedes that’s correct. Um???
So I start to pepper her with specifics plucked from my prior two year medical history.
“What about my pap smear? Should that fall under the deductible? Cuz it was paid for?”
“How about my allergy shots? They paid for the testing, and all the lab work but not the shots. Should that fall under the deductible?”
“I have this billing for in-office surgery. Should that be part of the deductible, cuz they paid for it.”
In essence, I confused the hell out of them. The final result is that she asked me to print out the EOB’s in question and send them to her, so they could look them over. Right, so even YOU don’t understand the plan and how it’s managed. That’s very comforting.
Here’s the other HUGE problem. I asked for a benefits book because the insurance company doesn’t handle that end of it. “Sure, we have those but they’re just summaries”. That means generic information like “covers 80% of dental procedures” but no mention of that “vanity” nitrous. What it MEANS is that you, as a consumer, CANNOT GET ACCESS TO YOUR HEALTH INSURANCE PLAN.
Think about that. You’re paying a ridiculous amount every month, and you don’t know exactly what and wherefore you’re money is going. They give you nothing in writing; they won’t even tell you who makes the ultimate decisions. They have complete control over how much and when they’ll pay for a provider or service. “Trust us”, they say when you call with a question or concern. “Go through mediation” they recommend when your claim is repeatedly denied. Mediation for what? For a system that purposely keeps you ignorant, changes the rules whenever the mood strikes them and for no reason other than they want to?
I am an informed consumer. From their perspective, I’m a giant pain in the ass because I won’t shut up and just pay their bills. But I can guarantee I would get nothing resembling “fairness” or “justice” if I truly tangled with these bastards. They hold ALL the cards. I, on the other hand, have nothing but hearsay.
When I buy a hairdryer, it comes with a twenty page booklet. When I register at a webpage, I have to read and agree to Terms of Service. So how is it legal that health insurance companies purposely DONT disclose this information? On what planet do I have more consumer protection from hot coffee than I do a corporation that is designed to take care of my physical and mental well being?
That’s how it works in a country that views access to health care as a Priviledge and not a Right.