Insurance Rant

This morning, as we do every morning, Mark and I watched Good Morning America. Today, Chris Cuomo reported on an insurance company that denied a claim for a newborn baby, saying the baby's condition was pre-existing. HUH? The baby was born with the problem. Short version is that the parents called GMA and asked for help. Once the cavalry rode in, the insurance company agreed that it was a mistake and that the baby's medical bills would be covered.

The report ended with a reminder to everyone to check their Explanation of Benefits forms when they arrive. Be sure you check that the coverage you are paying for is being provided, and never assume the insurance company is right. The report came right out and said that it is common for insurance companies to deny things that they KNOW they are supposed to pay. Complaints against insurance companies for wrongfully denying coverage are common and well-known to consumer experts. It was reported that it is to the insurance companies benefit to try to save money by denying things. Unless the consumer calls them on this, they get away with it.

Mark and I sat there with our jaws dropping because for the first time anywhere we were hearing in public what we have been saying to each other and to anyone who would listen for years. Our insurance company denies payment for covered services about 50% of the time. When our Explanation of Benefits forms come in, we go over them with a fine-toothed comb. Often they say we did not turn in the proper referral. This is never the case. We always have the referrals. It sometimes means calling the doctor's office back and asking where it went. Sometimes it involves multiple phone calls before someone in some office admits the referral is there but wasn't sent, was overlooked, was not inputted correctly, whatever little excuse they can come up with at the time. Sometimes the mistake is on the part of the doctor's office who originally took the form, and sometimes it is on the part of the insurance company who somehow miraculously finds the referral when you call them on it.

Which brings me to my latest insurance round. Yesterday, I received several Explanation of Benefits. One was for the surgeon who performed my partial mastectomy, node dissection, and ventral hernia repair on September 16. It was covered 100%. A second was for the anaesthesiologist who administered anaesthesia to me during that exact same surgery. It was paid at Level 2, in network but without a referral, 85%. HUH?

This morning I called the insurance company and was informed that although I had referrals on file for the surgeon, I did not have one specifically to the hospital itself. HUH? I have had lots of surgeries, sadly, over the years, both in and out patient. Never have I been asked to turn one in to the facility itself. Once the referral goes to the surgeon and says evaluate and TREAT, the treatment, if it is surgery, has been covered, including the facility and any other attending doctors. Now this is not the case, apparently. The nice lady at my insurance company informed me that I could still have my primary care doctor fax them a referral for the hospital facility today. I called the primary care office and my doctor's assistant was very helpful and said she would get it done right away. They are always so nice there, but even she was mystified by this. She was as surprised as we were that this was necessary. She could see in my file the many, many referrals that have gone out there. August 19 I gave one to the St Agnes Breast Cancer Center for the multi-disciplinary team meeting and 99 visits to radiation and oncology to treat my invasive lobular carcinoma of the left breast. That visit was covered 100%. I thought that was the big umbrella referral for everything, but apparently not. I now have on file one specifically to the radiation oncologist and to the medical oncologist, 99 visits each. When I was called by the hospital for the pre-registration for the surgery, I asked them if everything was in order and they said yes. I guess we were all misinformed.

To me it seems that the insurance companies perpetrate fraud knowingly and often get away with it. People do not look at these Explanation of Benefits forms enough or question them. Then bills arrive from doctors, and people pay them, assuming they owe them. It's a racket.

Our advice to everyone is be diligent. Check your benefits, be aware of levels of coverage, advocate for yourself. At the end of this year my retirement office is dropping this insurance company, and I will be selecting one of two new plans, both offered from a different big insurer. We also will be selecting from among a wide variety of plans offered by the federal government through Mark. I don't know if the next companies will be better or not, but I will not miss this one at all.