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Posted 3/27/2015 5:51 PM (GMT 0)
I’ve been having an interesting “experience” dealing with my insurance company (I would call it a Cadillac Plan).

In November, I went to the Mayo Clinic for a C-11 Choline scan. Well, it turns out there is this neat little clause which they (my group insurance plan at work) point to with pride as a selling point to new employees. When you have to go somewhere for specialized treatment at a designated Center of Excellence, that is not covered anywhere else, they will pay for your transportation and lodging (and maybe food – I never checked that). Well, the C-11 Scan is ONLY offered at Mayo, certainly a Center of Excellence. PERFECT! So, when I got back home, I remembered the clause and checked with them. They first made me go through the doctor hoop. I needed a letter from Dr. Lam attesting to the necessity of getting that test. I did that. Eventually, it got approved. Supposedly the check was issued on a certain date (confirmed on their web-site) and was sent to me the day after. To make a long story short, I didn’t receive the check and had to call them multiple times. Each time they confirmed my eligibility and stated it was sent out. I finally got the check about 5 weeks later. It was not mailed out when they said it was. In fact, it was mailed out the day after the last time I spoke with them (about 4 times).

Fast forward to now. I did have to get the scan pre-approved. They did. The scan and related expenses was about $7600. My cost ends up being about $650. That was as expected, since Mayo is in network. Meanwhile, I have another bill for the MRI, lab tests, doctor expenses, etc. It amounts to about $6500. My cost should be much less (a negotiated discount and then they pay 90%). Well, my EOB has all that, but they only paid 70% (typical when OUT of network). Meanwhile, Mayo is not recognizing the negotiated discount and keeps sending me a whopper of a bill (about $6000, including the aforementioned C-11 portion that I owe). I call Mayo. They say the bill is correct, since they are out of network and have no contract with my insurance company. They have no contract with my insurance company and they do not recognize any “negotiated discount.” So, I call my company. They said they think Mayo is in network but they will call me back by XXX. Needless to say, no call by XXX. I called. Again, no call back. I called a third time and was much firmer with them. They did call me back and confirmed Mayo is in network, hence there is a contract and I have it right. They also spoke with Mayo. Supposedly everything will soon be corrected, but it won’t be in April and probably not even in May.

We shall see. But what a bunch of you-know-what. Isn’t it amazing that every error seems to be in the insurance company’s favor? Mayo’s too. I try not to be paranoid, but is that the new game? They force me to follow up and then follow up 5 more times before they do what they are supposed to do? What happens when the symptoms worsen and one doesn’t have the energy or smarts or gumption to stay on top of things. It’s really irritating.

Speaking of irritating, I see the vampire on Monday. So, I am annoyed already!

End of rant!

Mel
Posted 3/27/2015 6:22 PM (GMT 0)
OUCH.... Guess I won't rant about my little situation.

URO forgets to call in my T Meds script
CVS finally gets that. Will have order ready in couple of hours.
Two days later they are processing the order
Next day - all of a sudden they are out of stock
Few days later - insurance company wants letter from doc
Today I call doc and insurance company. Neither have called back.
Posted 3/27/2015 6:31 PM (GMT 0)
Mel, I got your first four checks. Thanks very much.

Jim

P.S. I don't think this is new. I remember my wife helping my in-laws 20 years ago with similar insurance and hospital issues.
Posted 3/27/2015 6:34 PM (GMT 0)
In the end, there is no doubt that the insurers are the ones who ultimately decide what treatments we get. The threat of bankruptcy if one goes against the insurer is real. To inject a slight "political" comment, there are those argue that they don't want a 'government drone' deciding on their care are missing the point that nameless insurance clerks are making those decisions for us now.

Hang in there, Mel. It's been suggested elsewhere that when these things happen, the thing to do is to send copies of the EOB to the provider and tell them to work it out with the insurer. I've never tried it, so I don't know what would happen.
Posted 3/27/2015 7:03 PM (GMT 0)
Mel, I sympathize. It is horrible, and they impose upon a lot of sick people who are least able to fight their way out of this jungle.

I blame both medical billing offices and the insurers. I'm usually not cynical, but I think that medical billing offices bill patients with incomplete data in order to get their hands on the money. Once they get their hands on the money, good luck getting it back. They intentionally overcharge thinking that they may have to settle for less. For one procedure I got (for essential tremor), I was charged $1,000 on one bill and $5,500 a year later - and it was the same insurance company. I refused and asked for justification - they still haven't responded. I always wait for at least a couple of invoices because they frequently "adjust" charges. Doctors are implicitly complicit too - just try asking your doctor in advance what a given procedure will cost, or whether what they are ordering is covered by insurance. Usually they just shrug their shoulders - "not my job to know." What else do we buy without knowing the actual cost first?

This won't change until we get a single payer system, but I don't see that happening anytime soon in the US.

- Allen
Posted 3/27/2015 7:14 PM (GMT 0)
There's no doubt that it's a mess. I remember a conversation some years ago with someone at my insurer, trying to find out if a particular procedure would be covered. After several non-answers, the person finally told me that she actually didn't know what was in the contract. Further she told me that she couldn't say anything of value because if I was recording our chat and she told me wrong, that she, personally, would be held liable. Amazing.

Any system that has 2 billing clerks for every physician in a practice just to deal with the dozens, if not hundreds of different insurance policies is insane by definition.
Posted 3/27/2015 7:23 PM (GMT 0)
That's nothing.
I had hip surgery in December. After various checks with the insurance, I was suppose to be covered in a preferred network. The hospital received my insurance card, but assumed I was on a different plan. The plan I was on was not a preferred provider. I am now getting bills for $15k.
The estimated you receive are not binding, so in essence they're pretty much worthless. The provider can check on the individuals insurance, but they say it's only as a courtesy. You can get different answers from the insurance company itself but it doesn't matter because they will say it's up to you to know the eob inside and out.

My gut says I'll owe 15 grand no matter what. All I can do at this point is appeal to the provider.

This is why I'm going back to a HMO.
Posted 3/27/2015 8:28 PM (GMT 0)
So sorry about this hassle. My husband was Dxed a couple of weeks ago, thanks to an elevated PSA at a yearly routine exam. We learned then that our insurance stopped covering PSA tests for routine exams. We are at a major university, and no one was ever told -- they just stopped covering it two years ago. Do other of you have routine PSA covered?

My best,

Mary
Posted 3/27/2015 8:41 PM (GMT 0)
Yes, my PSA tests have always been covered.

I have a Cadillac Plan with tricycle service

Mel
Posted 3/27/2015 9:37 PM (GMT 0)
The real shame in this is... here's a person with cancer and should not have to deal with these issues. The government, the insurance industry, the healthcare providers or any potential future healthcare "solutions" seem to have absolutely no compassion for the patient.

...Jerry
Posted 3/27/2015 10:43 PM (GMT 0)

compiler said...
with tricycle service

humm, you sure they have enough intelligence to ride a tricycle?

Andrew
Posted 3/27/2015 11:02 PM (GMT 0)
Never forget that a medical insurance company exists to make a profit, which means paying out less than they collect in premiums and earn on the market. So, their business is, ultimately, to deny claims. And, the clerks who craft EOB's get bonuses based on their payout ratios.

Ultimately, however, it's not really fixable by market based approaches. Medical care is more like a public utility, which is a natural monopoly that everyone needs. When it comes right down to it, guys, how many of us considered the price tag on the various treatment options we considered? Or, did we base our decisions on all the other factors (experience, personal preference, side effects, etc?). Do we really WANT a market based system?

The insurers count on the average person's unwillingness to fight the system, and they also bank on the knowledge that huge unpaid claims are left to the provider to deal with...and are frequently written off. I'd really love to find a hospital expert who can explain how hospital finance works. It doesn't seem to "work" by any definition of the term I've ever encountered.
Posted 3/27/2015 11:04 PM (GMT 0)
I can't even count how many times I've had to resubmit claims to my health insurer two and three times, because the "never received it" I'm not a conspiracy theorist, but......whatever, pretty disgusting that with all you are going thru MEL, you and others, need to deal with this crap


PJR, I tHink most insurance covers routine PSA tests as part of a regular checkup, despite the geniuses on that whatchamacallit panel that decided PSA tests for routine screening are a waste.

I think your insurance company not covering them is a class action suit waiting to happen. I would threaten the s**t out of them with bad publicity. But that's just em, I actually enjoy py having those confrontational conversations. Don't matter if it's an insurance company or Verizon
Posted 3/27/2015 11:40 PM (GMT 0)
I understand it is a business. Fine. Let the actuaries and experts do their thing and craft a contract and charge a premium.

Then,,,ABIDE BY YOUR &*^%$#-CONTRACT!

Frankly, how is this not fraud. Or, since they eventually pay after the wise patient manages to summon the energy to run a marathon vs. the
insurance company, how about INTENT TO DEFRAUD.

Seriously, how does the poor suffering patient even find the energy to fight? And these insurance companies take total advantage of that. It is disgusting.

Mel
Posted 3/27/2015 11:45 PM (GMT 0)
And I believe that's what they count on. That a certain number of patients WILL decide they don't have the energy, and will just pay up. Pretty disgusting
Posted 4/3/2015 12:13 AM (GMT 0)
Update:

I just got about 15 new EOBs from my insurance company. They are now doing it right.
They have a negotiated discount (will Mayo recognize it THIS time) and then they pay 90%, which indicates that Mayo IS IN NETWORK and there is a contract.

Even better, it turns out that they are paying 100% of some of my expenses because I have now exceeded my out-of-pocket in-network maximum. (Very nice, but too bad we have to deal with any of this -- darn PC).

I'm keeping my fingers crossed that all will be smooth from this point on. As I mentioned in my original post, my insurance company dragged their feet recently when they said they mailed a check, but did not for quite awhile. I still need Mayo to acknowledge that they are in network and hence what the EOB says I owe us what I actually owe!

But getting the correct EOBs is a good sign.

Mel
Posted 4/3/2015 1:07 AM (GMT 0)
Mel, sounds like you finally pushed the right buttons with the right people.
Posted 4/3/2015 2:54 AM (GMT 0)
This is happening in every facet of our society. It will get worse be fore it gets better… not before the 22century. At least straight out thieves, don't pretend. As far as, "not my job" employees, you need to be rudely forceful, without an atom of guilt. BTW on another issue did you folks know that there is a federal law that requires you to a 100% refund on a non refundable airline ticket, even foreign carriers, if you cancel within 24 hours of making the reservation. It came to mind, as I just did it. As soon as the person on the phone started hemming and hawing, I demanded an got a supervisor and got the ticket fare, but he used some double talk to say they would not refund the 400 for 2 premium seats r/t that was in the fare also. No worries with a few more phone calls I got that also. New world ,new tactics. As my wife says she wasn't worried " you got da mout " pidgin rhymes with bout, like in boxing.
Posted 4/3/2015 3:07 AM (GMT 0)
My company insurance pays for two PSA tests per calendar year. I can get reimbursed for one from an AFLAC policy. The fourth I get comes out of my pocket, but at the "discounted" rate that I can pay from my HSA account.

Not sure what will happen this year, as my testing (lots of tests that are for the company "annual") change in April to monthly. The oncologist is ramping up the tests, as all my numbers went seriously sideways in March.

We shall see.
Posted 4/3/2015 1:20 PM (GMT 0)
I have had significant issues with the hospital from my wife's breast cancer treatment that finally I had to escalate to the highest appeal level just short of filing a law suit.   Thankfully we were successful.

I now use the following procedure when dealing with the insurance company customer service rep.  First I require a full name and job title.  If they won't give it I escalate immediately to the supervisor.   Second, I ask if we are being recorded, which I know we are, but it reminds them of it.   Third, I ask for the specific instructions as to how to get a copy of the recording.   If the CSR can't or won't provide me the information, I immediately escalate to a supervisor.  I take meticulous notes and request an email confirmation of the conversation.   This way they can't spoof me or claim ignorance (incompetence) on follow up calls as this is in their conversation notes history that most companies retain.    Every time I have done this, I have gotten results and accurate follow through. 

Thankfully, our group insurance broker maintains a troubling person that is our advocate and she is very adept at cutting through the red-tape and BS.   Still problems occur and we have to be diligent.

Posted 4/3/2015 3:00 PM (GMT 0)
JNF:

Right on, but it is so important to take good notes (especially the name of the person you contacted) and not let things go. The PROBLEM is that if you are very ill and lack energy/brain function, it is an impossible task. These companies take advantage of that.

The most important thing you mentioned is having a good contact person. My local person has been so helpful in following up and cutting through the red tape and other obstacles. ("troubling person"? I think you just mean knowledgeable contact!)

With all that's gone on, I have gotten a tad jaded. So, I'm HOPEFUL that it will be clear sailing from this point on (ie: Payment is made and Mayo accepts the "negotiated discount")

Mel
Posted 4/3/2015 4:15 PM (GMT 0)
It really does appear that in some cases, another member of our "treatment team" needs to include an expert in navigating the insurance mess. There has to be a better way.
Posted 4/3/2015 4:17 PM (GMT 0)

pjr64 said...
We learned then that our insurance stopped covering PSA tests for routine exams.

Anyone in this situation should know that you can order your own lab tests at a cost much less than the list price of the major labs. There are several online sites that let you do this. I use privatemdlabs.com. They charge $47.49 for PSA and email you an order for LabCorp. Plus once you get on their email list, they send you a 15% discount code every month. I've been using them for 6 years just for tests that I have wanted on my own. Due to state laws, this type of service is not available in NY, NJ, MA, MD or RI.
Posted 4/4/2015 1:32 AM (GMT 0)
Just to add to the thread: My dad's got Medicare supplemental through AARP (United Health). United has defined Trelstar (not state of the art treatement, mind you) in the same bracket as Xtandi and Zytiga - their highest bracket, which means he has to pay 33% of the "market cost" of Trelstar everytime he needs to get the shot. Last time he had it, it was slightly over $700 for a three-month shot. You can imagine what he would have to pay to get Xtandi for 12 months...

Criminals...

Arthur
Posted 4/5/2015 3:06 PM (GMT 0)
Arthur- Is there any way to appeal that? I would definitely try to look into it. also possibly some copay assistance? Seems I had found some help somewhere and was surprised at very high income limits for the programs. At least some do "get" that you can look good on paper with income but with cancer that all goes right out the window. I am going to see if I can locate that....
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