Even with supposedly quality coverage, ultimately what you “have” is a relationship with a company with a fiduciary responsibility to seek out ways to withhold reimbursement. What you “have” is defined not only — not even primarily — by the letter of your policy but by the persistence of your advocacy. An exchange may mitigate this, but it’s not an enforcement or advocacy body.

Usually, this applies up to some total out-of-pocket expenditure on the subscriber’s part. Thereafter the insurance pays all. But this is not always the case. Wierd stuff can lie buried in the policy details.

A friend of mine with a supposedly very good insurance package had to have three back-to-back emergency surgeries at an unbelievable total cost. He didn’t know that his insurance had both a co-insurance provision and, apparently, a maximum benefit. He’s a relatively well-paid professional in a two-income household. Yet he had to sell his cars just to pay down part of what “good” insurance wouldn’t cover.

I’m still reeling from receiving, just yesterday, the EOB for my daughter’s annual physical and immunizations. We have “very good” insurance and NONE of it was covered! None. And I was astonished at the cost of two of the shots. I feel stupid for not asking, but I figured all immunizations are in the same ballpark. Now I know.

Needless to say I have some phone calls to make.

Recently, a close relative was diagnosed with breast cancer, did chemo, and had a lumpectomy. There were complications resulting in a dangerous clot, and the dear relative had to be on a long course of injectable blood thinners. Normally, these drugs have to be administered in a hospital, but the relative is herself a healthcare practitioner and more than qualified to self-administer. Her employer’s plan handbook explicitly covered this option. So I showed up to help pack her things while her discharge was being processed and while the insurance pre-approvals were being arranged by the physician’s assistant.

The drug was denied. The PA, the hospital’s patient advocate, the patient herself, and I all ended up on the phones. For about 5 hours. We were all shuttled from one ill-educated call-center staffer to another, each of which claimed nothing could be done, and then from one supevisor to another. I suspect many would have given up. Both the patient, the hospital advocate, and I all had some connection to the medical industry and knew enough to insist and hang on. Discharge did not happen. The patient stayed in another night. The weekend was coming up. I had to get back to work.

Finally, the next day, the patient got through to a 2nd-tier supervisor of some sort who initially tried the same line as her underlings. We again read her the relevant passages from the patient’s benefits handbook, but the supervisor claimed that there was nothing she could do. The dear relative then said that she was relieved, because this meant that she could get her doctor to admit her again and could stay in the hospital for the full 2 or 3 weeks of treatment. The rest would do her good. She described the comfortable surroundings (it was rather nice), and started to hang up. At that point, the supervisor “discovered” that the rejection was caused by the drug being erroneously listed in their database as “hospital-only”, and that any supervisor could override this and approve the treatment. Dang computers.

So I took the relative home and then went to her pharmacy to get the drugs–the PA had called ahead to be sure they were in stock and ready for pickup. No drug. The pharmacist said that the insurance would not approve it. I threw a cold icy fit. They checked again, twice. Denied.

Luckily, the PA had given the relative some samples for use that night. The next day, we started working the phones again and went through the same rigamarole. Even though we explained about the override, no one seemed to know about it. I got on the phone at that point, got very dramatic about the danger to the patient’s life, and announced that I had called her doctor and we were having her admitted. Suddenly the supervisor that knew about the override (oh, THAT override). She explained that the override just hadn’t taken when her colleague did it the day before–something with the computers. Right. But I just kept her on the line while the relative called the pharmacy and had them run the approval while we waited.

I concluded that the whole thing was an organized policy of delay intended to discourage claims or at least string them out for as long as possible. Perhaps the claim does not count against their boss’ bonus if approval slips into the next shift. Maybe they hoped to avoid paying for at least one day at $120 a day. I don’t know. But the bottom line is that the tactic cost the insurance carrier an extra day in the hospital on a specialist cancer ward, a charge that dwarfed any imaginable savings from the medication. Moreover, two highly compensated professionals–the PA and the hospital’s patient advocate–spent a lot of billable time on this, time that gets added on to everyone’s bills eventually.

The mere fact that both the hospital and the oncologist have these patient advocates is indicative of the source of runaway costs. I talked to the advocate at the hospital at length. She was a Licensed Nurse Practitioner (MD in all but name) who works exclusively on forcing insurance companies to live up to the letter of the policies they have sold. She showed real Crusader spirit, and I was glad to have her. But can this be efficient under anyone’s business model?

One final straw: after the surgery, the complications, and the radiation, my relative needed to take a relatively new type of drug to prevent recurrence. There were three different ones available, all with varying but significant side effects. All very pricey. NONE of them were in the insurer’s formulary. The plan handbook said that, in such cases, the drug would be covered. But the call-center staff and supervisors insisted that these drugs were in a special, high-cost category.

The relative was, by this point, taking no prisoners. She said she understood and asked to be transferrred from the drug pre-approval department to surgical pre-approval. Why they asked? She was going to schedule a bilateral radical mastectomy with reconstruction, since she couldn’t have the preventative treatment. Why take the risk? They approved all three drugs then and there–whichever she tried and tolerated best would be fine.

The relative is a hardcase beneath the ladylike exterior. And she is a professional that knows the healthcare racket from the inside. But how many less determined or less knowledgeable women die from willful insurance malpractice without anyone knowing? And how much are the carriers charging us for killing other peoples’ relatives and pocketing other people’s money?

P.S. The relative was coverd by one of the best plans offered by one of the two or three largest private heaqlth insurers.

Do you understand that the best path to fix these problems is taking the insurance companies out of the picture?

amen.

it may even be the only path.

as ralphbon wrote:

A public option plan is the irresponsible, wild-assed gamble; single payer is the boring, conservative, proven solution.

Who will advocate for patients?

margot, you just did. thank you.