Saturday, August 15, 2009

America's Great Healthcare Denial of Service (guest essay)

Editor's note: During the current health care debate, some have claimed that government run health care or health insurance would result in a bureaucratic nightmare where needed treatment would be denied by bean counters. The reality of Medicare for All (single payer) is a topic for tomorrow's guest essay. But today's essay is just one of many examples of how the present system is, for too many, already a bureaucratic nightmare where needed treatment is being denied by bean counters. Here is one local man's Kafkaesque story with our private health insurance system.

America's Great Healthcare Denial of Service
by Ben L.

In October of 2008, I began trying to verify with United Health Care
(UHC) what my out-of-pocket expenses would be for covering Remicade
infusions (for treatment of Crohn's Disease). After many phone calls, I
received assurances in January of 2009 that the procedure would be coded
and billed as an office visit and I would be responsible only for the
$25 co-pay. At this time, I was coordinating services through my doctor
as well as the hospital.

In April, I received a bill from Glens Falls Hospital for $1,677.09.
This was for my first Remicade infusion for the year.

I called customer service on at least four occasions from April through
June being told on one instance that the claim dispute had become a
"project" and someone would get back to me. I was directed on June 2 to
submit this as an appeal (no word on what became of the "project").
When asked what to include in the appeal, I was told only write a letter
and send it to the address for appeals that they provided.

On Saturday, June 20 I received a letter denying my first level appeal.
I never talked to anyone from United Health Care about my appeal. I want
to reiterate that the assurances I received about coding and billing
these Remicade infusions as office visit co-pay were out of a
three-month long process of multiple phone calls and questions about my
Remicade infusion. In fact, the hospital will not even give me the
infusion without first receiving pre-approval.

The facts related to this pre-approval process were never addressed in my
initial appeal or secondary appeal. Instead, they made it sound like this
pre-approval process and statement of their coding and billing process
is based solely upon the whim of a customer service representative and
that "information given by Customer Service Representatives is not a
guarantee of payment."

What is the point of pre-approval and the months I spent trying to
coordinate between the hospital, my doctor's office and my insurer if
the insurer can decide to choose different terms than what it states
before services are provided?

While spinning my wheels with getting this issue addressed (it still
remains open as you will see later), I received another bill for a
colonoscopy that I had to have in April. This time, I was being billed
because my doctor is not "in-network" (a point that was never addressed
during the pre-approval process). I called and said that I thought that
I would be eligible for a waiver as there are no in-network
gastroenterologists in my area. UHC said that while this is true, the
waiver can only be given before the procedure. Why would it make any
difference before the procedure or after the procedure?
It is a waiver for crying out loud! They denied this twice as well.

Meanwhile, I also sent in some complaints to the New York State Insurance Deptartment. After several weeks, they notified me that my company's plan is out of
their jurisdiction because my company is self-insured and UHC is merely
administering that self-insurance. If I had complaints, the appropriate
agency would be the United States Department of Labor.

About that same time, I also was pointed by UHC to address subsequent appeals to the company's employee benefits committee. I have forwarded on more words to these people as well.

Since then, I have been hit by another $600+ bill to bring my total
in-network responsibility to $2400 while also keeping that out-of-network expense for the doctor for whom I didn't get the timely waiver at another $645. I have a thick folder at my desk from different letters I've sent to different people all around the country for these bills. I still feel like I haven't even spoken to a person who has a clue on how to address the discrepancy between what I was told I would be responsible for and what I have been billed (bilked?).

Universal health care anyone?

1 comment:

Unknown said...

Kafkaesque? Cal my Gregor.