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Frack "health" "insurance"

a little night musing's picture

I still owe Correntians a post about the history of part-time coverage at City University, but...
Every. Single. Doctor. Bill. That. I . Have. Had. Has. Been. Denied. By. The "Insurer".

ALL OF THEM. Including the original bill by my PCP (That's not my PCP, according to "Insurer")

I could not walk.

I had to have a toenail removed, because it continually re-bled - this is routine foot care, according to my insurer.

They cut off my Physical Therapy when I was (barely) able to walk again. This, apparently, is a feature. "Functionality" yay! (Not)


Submitted by lambert on

I don't know how to dispute insurance companies, but maybe others do.

a little night musing's picture
Submitted by a little night ... on

Thanks, Lambert, but I'm still able to find ways fight this for now.

Fortunately for me, I am good at figuring things out, I know how to get information and I know how to analyze it, and I have people to help me if all else fails (and I count you in that corner, Correntians!) But not everyone is so lucky.

I fell as if this deserves a fuller post, though. The denials have all been for BS reasons and ambiguities in the coding system. Really, it's a lesson in how fracked-up our so-called health care system is, and it can only get worse in these respects under the so-called "ACA" I've had to learn way more than I want to know about diagnostic and treatment codes. (It's become a part-time job!) Apparently a lot of insurers used to rely on the requirements of Medicare to figure out what was covered, but now it's just a shot in the dark.You'd think the doctors' offices would want to make sure that they are coding things according to the insurer's arcane requirements... and they do... but so much slips by, they rely on patients interfacing (did I just use that word?!) with the insurers to figure out what they need to do.

Let me just give you an example: one (only one) of the referrals I got from my PCP (And I don't want to stay with her, but that's for another post) was for a podiatrist to deal with a subunguinal hematoma (If you don't want to follow the link, which you don't: an accumulation of blood under the nail) of the great toe, probably related to the other stuff that was going on. The podiatrist determined that my toenail had to be removed. Let me assure you: I've had subunguinal hematomas before this. Usually they grow out, no big deal, the nail eventually falls off and a new one grows in. But this one kept bleeding new blood and needed to be removed.

The insurance company denied the claim because (they said) it was "routine foot care".

Yeah, I have my right big toenail removed every year whether I need it or not.

Oh, I haven't even started to tell you how they have screwed up my coverage for flu shots. I teach college. 'Nuff said.

a little night musing's picture
Submitted by a little night ... on

My so---slow internet connection wouldn't let me fix these:

Subungunal hematoma (dont't follow this link if blood-shy):

And I cannot say enough about how much I appreciate the community here. For those of you who want to make a better system: what can I say? I love you, I join you.

NWLuna's picture
Submitted by NWLuna on

They don't have to have a good reason for denial. I speak from the healthcare clinician point of view also. Every year the ins co's get worse and worse. They just do it because they can. Part of their strategy is to discourage you (and all the others they're screwing over) so you'll be disheartened at the time and hassle, and give up.

After all, they're not in business to do the right thing but to make money.

Submitted by hipparchia on

they game everything.

based on my own experiences + a fair amount of reading, i'd say they all have algorithms in place that automatically deny everything once you've reached the deductible.

they also have numerous algorithms for predicting which patients are likely to get "too much" care (read: need to use their insurance) so that they can be proactive (read: keep you from using your insurance).

a little night musing's picture
Submitted by a little night ... on

Do you doubt it?

I hadn't even reached my deductible (=0, by the way: which may have been part of the problem)

My union's Welfare Fund is breaking the bank to maintain this level of "insurance", and meanwhile, I can't even get them to pay for a friggin Flu shot!

If I get the flu, I'm totally going to pass it on to them. Because. Reasons.

Alexa's picture
Submitted by Alexa on

but I've filed and won an appeal regarding a Lab expense, and "went-up-the-chain" and obtained an exception to the provider network--both with Mr A's self-funded medical insurance plan.

Our plan is "administered by" a major insurer, BTW.

Number one, you definitely need to know the plan benefits.

Regarding the "exception" on the provider network--a representative actually told me that I would have to travel approximately 15 miles to the next town (much smaller) to see an in-network doctor.

Apparently, none of the specialists in this town, because of low reimbursement rates, would accept our policy (underwritten by the largest insurance company in the US).

I raised heck, and insisted upon talking to the next level representative (supervisor).

Apparently, she thought that it was reasonable not to force an individual with a huge cast on their foot (fractured ankle) to drive an additional 12 miles to an in-network doctor.

I pointed out the "safety" risks, of course.

So that time, I got a "waiver" before the fact.

In the other case, went to our group plan insurance pamphlet, and followed the instructions to file a written appeal. Sent one certified letter, and got desired results (they paid my lab fees.)

FWIW. ;-)

Rainbow Girl's picture
Submitted by Rainbow Girl on

Not because I'm a sadist but because I've been collecting them for some time with the vague idea of writing them up in a tome. So thank you!

"Apparently, none of the specialists in this town, because of low reimbursement rates, would accept our policy (underwritten by the largest insurance company in the US)."

Wow, place this quote next to Lambert's post of this evening on NYT discovering (!) that ACA Products are being carefully crafted around Skinny Networks (Because More Affordable Policies), and voila -- ACA just perpetuates the worst of what already exists in the private insurance market. Perfect pair of items to illuminate the point.