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[cancer] The magical power of health insurance to sap the soul and drain the mind - Lakeshore
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Jay Lake
Date: 2010-01-04 17:30
Subject: [cancer] The magical power of health insurance to sap the soul and drain the mind
Security: Public
Tags:cancer, health, healthcare, personal, politics
Every single time I see my oncologist, my insurance carrier informs me by mail a few weeks later that she is out-of-network and pushes the entire claim to my (substantial) out-of-network deductible. Every single time, I call my insurance carrier and wrangle with them, until they admit she is in fact in-network, and reprocess the claim. These calls take up to an hour a pop. Every call is as if no such call had ever taken place before in the history of time. Completely ab initio, always.

I have had the clinic call the provider line. The carrier's provider line people have repeatedly assured the clinic that my oncologist is in-network. There is a data mismatch between the provider database and the claims database, because my oncologist is never in the claims database.

Today's call was especially frustrating, because the front line rep I spoke to told me that none of the 2009 claims for my oncologist had been paid, they were all being held to be reprocessed as out-of-network. (This is a difference to me between $40 per visit and almost $300 per visit.) I knew this couldn't be true, because I'd have a stack of nastygrams from my clinic's billing department if all those visits had gone unpaid. When I asked for a supervisor, my call got dumped. I finally fought my way back through the automated menus and two layers of reps for another supervisor, who told me the same thing the front line rep had told me. I dogged him, politely despite my frustration, until he finally decided the previous claims had been paid by being reprocessed to the clinic's provider group code instead of my oncologist's (allegedly non-existed) provider code. He also told me they wouldn't do that any more, that I needed to get the clinic to bill under the provider group without including a provider name. All of this joy took over ninety minutes to work through.

The clinic, of course, has told me in the past that the carrier's provider line assures them my oncologist is in-network and none of this is necessary. I'm also very dubious of the carrier being willing to process a claim without any provider being named, since that seems like Fraud Risk 101 to me.

What it boils down to is a problem no one can fix, that I own, unless I want to start paying out-of-network costs. I will see this oncologist every two weeks for the next six months as part of my chemotherapy regimen, which means I will spend thirty to ninety minutes on the phone every two weeks for the next six months convincing my insurance carrier of the same damned thing every time, unless someone can fix this. And god help me if I were a head injury victim, or mentally ill, or deep in chemohead, say, and unable to be articulate, firm and persistent, and deftly employ the command of managementspeak and customer service lingo that my twenty-five years in marketing and sales have given me. Because basically, I'd be screwed if I weren't so overqualified at dealing with indifferent and stupid bureaucracies.

Meanwhile, they steal my time, sap my energy and morale and generally make my life difficult, solving the same damned problem every time.

So, all you conservatives who oppose healthcare reform because our current system is "the best there is" can suck on it. Kiss my cancer-ridden ass. My healthcare delivery is fine, even magnificent, but the magical free market private sector health insurance is a retarded behemoth that is sucking my time and energy which I could be using to almost any other purpose so much more effectively. A decent single-payer system, combined with the current competitive public-private provider network, would deliver exactly the same quality healthcare at a substantially reduced cost and a fraction of the hassle.

Every one of you "death panel" nuts and "don't let the Democrats win this one" political thinkers ought to spend a few months in my shoes. Then tell me how great the current system is. And I'm one of the lucky ones, in our current system.

Post A Comment | 23 Comments | | Link






wyld_dandelyon
User: wyld_dandelyon
Date: 2010-01-05 01:56 (UTC)
Subject: (no subject)
This is terrible!

Complain to the Commissioner of Insurance in your state. The magic words in Wisconsin are "bad faith" -- i.e. the insurance company is failing to process your claims in good faith. The potential of government fines might bring then into line.
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jtdiii
User: jtdiii
Date: 2010-01-05 02:08 (UTC)
Subject: (no subject)
Having that conversation with a friend who is convinced anything the government does must be bad. I keep trying to remind him that unrestrained capitalism is worse. There is a certain blindness that I find hard to understand.

Death Panels are real and already exist: They are called insurance review boards and they decide if they will pay for your procedure and when you hit your lifetime maximum of coverage you are on your own. Somehow the nuts forget about that.
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martianmooncrab
User: martianmooncrab
Date: 2010-01-05 02:12 (UTC)
Subject: (no subject)
depending on who your health insurance provider is, you can request and get a single POC to work your case. They used to have them at Regence, and it would save you time and energy best used elsewhere. I think they were called Case Managers but all of that might have changed since I stopped working there.
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Gary Emenitove
User: garyomaha
Date: 2010-01-05 02:33 (UTC)
Subject: (no subject)
One of my two ministers (the one I work for, not the one who works for me) says part of the problem is semantics. We're not looking for health care reform but rather health insurance reform. The bad guys have attached an incorrect name to the situation, causing confusion. Just like "public option" and other misleading terms.
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User: (Anonymous)
Date: 2010-01-05 09:37 (UTC)
Subject: (no subject)
/bemusedoutsider here/

It's reported that when Gandhi was asked "What do you think of Western civilization?" he said "It would be a good idea."

Same with these 'reforms'. Real reform of health and/or insurance would be a good idea -- if there's ever a bill proposed that would be real reform. The current legislation seems more a sell-out to the insurance and drug companies.

It forces people to buy their product, stops people from importing drugs from Canada, cuts Medicare so that those seniors will have to buy private coverage (sold by AARP), hampers abortion rights....

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mcjulie
User: mcjulie
Date: 2010-01-05 16:15 (UTC)
Subject: (no subject)
Big second to that. I've long been frustrated by the way both sides -- one from laziness and one from evilness -- casually conflate health care delivery with the mechanism by which it is paid for.

So they can say "government health care" as if proposed reforms have something to do with your doctor.

And it works, because people are often very pleased with their doctors and other health care professionals. But nobody likes their insurance company.
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calendula_witch: Tattoo
User: calendula_witch
Date: 2010-01-05 02:49 (UTC)
Subject: (no subject)
Keyword:Tattoo
I love my Kaiser. :/
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User: joycemocha
Date: 2010-01-05 03:30 (UTC)
Subject: (no subject)
Me too. But still, it took a year to resolve the ambulance bill when DH got transported from Timberline to Kaiser Sunnyside (about 60-70 miles).
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(no subject) - (Anonymous)
Jay Lake
User: jaylake
Date: 2010-01-05 14:18 (UTC)
Subject: (no subject)
I'm working on the billing department end already, but they've expressed bafflement as of yesterday.
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User: joycemocha
Date: 2010-01-05 03:35 (UTC)
Subject: (no subject)
Well said, sir.

Right now, any insurance is a PITA. Our house policy just came up again, and I had to remind them that a.) there is no mortgagor on this house as well as a few other things I had to pull together. Health insurance is the most complex of the insurance systems--but they're all obscure, obnoxious and outright screwy.
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ygolonac
User: ygolonac
Date: 2010-01-05 03:46 (UTC)
Subject: (no subject)
Being a claim processor for a large California insurance company, I'm guessing that your problem won't get fixed. There is no memory at the insurance company, for the most part. Yah, you know the problem and have had it fixed umpteen times before, but the processor that gets your claim next time is just gonna follow the workflow he is told to follow, exactly, even if he knows it's wrong.

I'm expected to process 25 claims an hour, minimum. 25 claims an hour makes me the lowest level of employee. As you can see, that's barely 2 minutes per claim. Not really enough time to give it much thought. In that two minutes I'm supposed to completely audit the claim and make sure the info in our system is the same as what is on the claim image, figure out why the claim stopped in our system and then fix that claim.

I have often been told to work claims in a manner that I knew was incorrect, but even when I let 'them' know that the workflow is wrong, I'm told to use that workflow till it's been fixed. And since everything is done by committee, it can take months for something to get fixed.

I really hate my job and the company I work for, but they do provide me with pretty good insurance, which is very important to me, as I too am a colon cancer survivor and will continue to have expensive medical costs for pretty much the rest of my life.
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seventorches: funny animal comic
User: seventorches
Date: 2010-01-05 14:02 (UTC)
Subject: (no subject)
Keyword:funny animal comic
I've often wondered about how insurance companies treat their own ill employees in these cases. Please, elucidate your experience. Do you have to go through the 7 levels of denials for every bill? Are you in danger of losing your job because you're expensive to cover? etc.
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ygolonac
User: ygolonac
Date: 2010-01-05 15:48 (UTC)
Subject: (no subject)
Nope. Never had a problem. On the other hand, when I went through my cancer experience, I had no insurance. It was only after that I got a job that had it.

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dinogrl: heart balloon
User: dinogrl
Date: 2010-01-05 05:21 (UTC)
Subject: (no subject)
Keyword:heart balloon
Jay, have you thought of unleashing this to the "liberal media"? Keith Olbermann perhaps? Or would this matter? The opportunistic blatherskite Rush was fanning the flames the other day with his best health care, but lacked the other side of the coin, insurance, which is a pile of...well...um...vile pile.
Yeah, paying out of pocket until I reach an impossible number isn't having "insurance".

I'm so sorry you're going through this, and damn proud you are able to have the strength to endure it. How unfortunate for all people in this wicked maze that we have to deal with it.
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markbourne: lloyd
User: markbourne
Date: 2010-01-05 06:01 (UTC)
Subject: (no subject)
Keyword:lloyd
By no means a direct map onto your situation, but a further case study delivered with a nod of sympathy:

Fifty-something days into my post-surgical Stygian odyssey this summer -- out of ICU but immediately before my scheduled move up to the Rehab floor -- our insurance company informed us that my time in the hospital was over. Today. No warning. Poof!, just like that. Didn't matter that the actual cardiac team was saying that no, really, I wasn't ready to leave yet. Tough, retorted the insurance bureaucracy rep, go find a nursing home and be out today, kthxbye.

This was coupled with a key Rehab unit physiatrist refusing to allow me up into his unit because my heart's telemetry had shown scary (to him) irregularities.

So on one hand we had a physiatrist saying I was in too bad a shape to move; on the other we had an insurance bureaucracy that had decided to halt my hospital coverage and therefore I had to leave the building entirely and immediately, destination unknown. (Just going home wasn't an option in my state.)

Elizabeth, already on the breaking point from stress and exhaustion, was livid. Explosive. Vesuvian. To this day they still probably speak in hushed tones about her response to all this.

It took my cardiac surgeon, of all people, to personally confront both of these issues at the same time because no way was he going to see me moved out from under his care. Not THAT day, anyway. Never mind other, you know, professional matters he might have had in his dayplanner. The physiatrist remained an immovable object, so the surgeon planted footprints on the physiatrist's head and went above him. The insurance company finally buckled when threats of litigation were mentioned (E having some instant day-job connections in that arena). "Not up to standard of care" is a powerful lightsaber in the insurance world. Plus, there was some higher-up head-butting that remains mysterious, although the upshot is that my surgeon ended up planting his boots on a couple of chests that day. (I'm assuming that at least one insurance case worker was out of a job by the weekend for handling the incident, as EVERYONE agreed, so very poorly.)

Sheesh. Obviously it worked out, though after a clash of titans that was apparently unprecedented. Certainly it should have been unnecessary.

Elizabeth's LJ posts about it are here, here, and here.
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Leah Cutter: Battle lines
User: lrcutter
Date: 2010-01-05 06:17 (UTC)
Subject: (no subject)
Keyword:Battle lines
One of the things that amazes me, again and again, is how often we need health advocates, people who will stand up to the system and say no. We had four people advocating for neighbor C. We were all connected via gmail and Google docs (as well as a Google calendar for Dr. visits, etc.) It took all four of us sometimes to see that the right thing got done. I do not envy you at all.

::massive hugs::
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A large duck
User: burger_eater
Date: 2010-01-05 07:20 (UTC)
Subject: (no subject)
Here's the website for Oregon Insurance Commissioner. The "Consumer Advocacy" phone number is in the middle of the page.
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mevennen
User: mevennen
Date: 2010-01-05 09:36 (UTC)
Subject: (no subject)
Dear God. This - and the comments - just make my blood run cold. I have no idea how I/we would have coped with this in similar circumstances - with C, it was all I could do to get up to the hospital every day and maintain things at home.

And this is one reason why I will fight for the continuation of the NHS.
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Autopope
User: autopope
Date: 2010-01-05 12:00 (UTC)
Subject: (no subject)
Ditto.

The US health insurance bureaucracy, seen from outside, is a Kafkaesque nightmare. Worse, it's one that doesn't even need to exist.
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Jay Lake
User: jaylake
Date: 2010-01-05 14:19 (UTC)
Subject: (no subject)
Seen from the inside, it is a Kafkaesque nightmare. Along with the banking system, the US health insurance system is the most clearcut argument I know for the inherent failures of market-based solutions.
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Chris McKitterick: Big Brother is Watching You
User: mckitterick
Date: 2010-01-05 19:58 (UTC)
Subject: (no subject)
Keyword:Big Brother is Watching You
No kidding. There's got to be a way to avoid having to deal with this every single time. Surely. Maybe your HR person could point you in the right direction?
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Kenneth Mark Hoover
User: kmarkhoover
Date: 2010-01-06 21:14 (UTC)
Subject: (no subject)
RepubliKans have one health care idea: "Crawl to the side of the road and die."

And they're okay with that.
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User: lindadee
Date: 2010-01-06 21:45 (UTC)
Subject: (no subject)
This may seem old fashioned, but WRITE A LETTER to your insurance company, certified mail, with a copy to the insurance commissioner. Document the problem, if you can, with the names of the people you spoke to and copies of the bills/receipts. It may take another hour or two to do this, but you may get better results.
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