Corrente

If you have "no place to go," come here!

Why, thank you, Democrats

This, right here, is why I will vote third-party in November:

From my mom, this morning:

"This is nuts. Our health insurance will cover the cost of "treatment for cancer." However, it will not cover the cost of incision and biopsy to determine if an apparent tumor is cancerous. We have been going round and round for over a month, and have one more appeal, but this is where we stand. Ridiculous. Why are we going thru this hell?"

My step-dad will be 55 in September. He has a past history of lung and colon cancer and now tumor has been found in his upper jaw. There is a good chance the tumor is benign, but we can't know that without a biopsy.

For the record, their insurance is Pennsylvania's "adultBasic" -- provided by First Priority through Blue Cross of NEPA:

adultBasic promotes access to quality health care by providing basic health insurance to Pennsylvania citizens age 19 through 64 who need coverage but cannot afford it. The program is intended to provide transitional health insurance for adults who either have incomes below 200 percent of the Federal Poverty Guidelines, who may have jobs that do not include health benefits or who are between jobs.

And what does adultBasic provide?

* Preventive care such as immunizations and routine checkups
* Doctor services
* Diagnosis and treatment of illness or injury
* Inpatient hospitalization/outpatient services
* Accident and emergency medical care
* Rehabilitation and skilled care (in lieu of extended hospitalization)

Apparently, however, diagnosis of cancer must be made with divining rods or tea leaves or maybe the reading of entrails.

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coyotecreek's picture
Submitted by coyotecreek on

Probably not unexpected (unless you're the patient/patient's family).

It seems to me that you have a shot with the promise of "diagnosis..." as part of the services that are (supposedly) provided.

What is scary is that they seem to separate each individual part of the actual biopsy - incision, etc. Do you have to provide your own bandaid in lieu of stitches? Hope you have your own scalpel!

(I kid - but it's no laughing matter....good luck!)

Submitted by PA_Lady on

Well, the problem is that it's considered "dental" until proven otherwise, and dental isn't covered. Of course, proving otherwise.... My mom is filing a complaint with the state insurance commissioner, though who knows if it'll help.

Believe me, we're trying to keep laughing because the alternative sucks. :)
And we're trying to count our blessings because we are luckier than most people in this situation because my parents do have the means to pay for the testing. It'll be a stretch, but they can do it. For far too many others, the cost of this simple test prohibits them from getting treatment. Your money or your life, literally.

sisterkenney's picture
Submitted by sisterkenney on

I have found frequently that non-coverage stems from inaccurate coding/descriptors by the biller. Have you contacted the surgeon's office/billers for assistance? When you call/write, just state simply that the procedure is indicated as a "diagnostic incision and biopsy", and could they check/help with the insurance coding/billing, and re-contact the insurance company?

Submitted by PA_Lady on

adultBasic is PA's low-cost insurance program for those with low incomes who don't have employer access to insurance, can't afford their employer's plan, are self-employed, or (as in my parents' case) have pre-existing conditions that make them un-insurable.

The procedure isn't scheduled to be done until Wed. It was when the surgeon's office called to get the pre-approval that they found out it wasn't covered because it's considered a dental problem. From what I understand, the biopsy itself is never coverable, even retroactively, because the tumor was found during a dental procedure.

At this point, we are pretty much calling anyone we think might be able to help force the ins. co to cover it.

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

Sisterkenney might be on the right track - although I don't envy your family having to wait to find out...

It occurs to me that maybe the comment I posted here belongs on this thread. Thanks a friggin lot, D's!

Submitted by WRhouse on

to quote the e-mail I received from PA Health Access Network

"adultBasic is the only affordable health insurance program for adult Pennsylvanians making just a little too much to qualify for Medicaid, but not enough to afford health coverage. 45,927 Pennsylvanians who otherwise would slip through the cracks currently receive health care thorugh adultBasic. Funding for the program is set to expire December 31st"

(Boldface mine)
We now have a name for the new PA high risk pool, hopefully starting sometime near the end of July, to quote that same e-mail

"The High Risk Pools, now officially called the Pre-Existing Condition Insurance Plan for PA (PCIP) may be opening up on July 21st, according to the PA Department of Insurance. To qualify you will have to have a pre-existing condition and have been denied coverage because of it or been charged at least 150% above the standard rate. Also, you will need to have been uninsured for 6 months prior to applying. There are limited spots available in this program and we expect it to fill up quickly. "

The fun thing is they have a video contest to win a gift certificate ($50/$100) to Borders Books.
(B and I mine)

Link

Submitted by PA_Lady on

Gee, I wonder if the end in funding is behind the denials of coverage? From what I've read today, it seems the number of denials is increasing.

As for "people who would otherwise slip through the cracks" -- adultBasic isn't really a help. The waiting list is currently about 4 years.

PCIP has been in the news around here with all the fundies doing a freakout. "OMGABORTION!!" -- except, the plan follows PA law as well as the Stupak amendment, which means no elective abortion is covered except in cases of rape, incest, or to save the life of the mother. I've been slapping down hysterics right and left over this during the last week.