More Insurance Fiascos….

Do people realize how messed up our healthcare system actually is? I seriously doubt it. Two quick stories:

Again, I have really good benefits. Even so, if you are sick or have a chronic illness, you really have to work at being on top of these things and you have to do so at a time when you feel the least inclined to do so. I can do it because 1. I don't have a choice, as paying for a covered service is not an option for me no matter how convenient, and 2. I understand the process, because I work for an insurance company, so I don't get taken by surprise. That gives me a huge advantage. Also, if you don't think an insurance plan is going to try denying something hoping that you don't contest it, then you've been pretty damn healthy. I promise they will do that.

My first example of the skewed healthcare system can be found looking over my recent claim just for a triple metatarsal bone fusion with bone graft. These charges are for the surgery alone; the surgeon, anesthesiologist and facilities and excluding charges for peripheral expenses such as diagnostics, medicine, durable medical equipment, consultation, follow up exams and the like. For the day of surgery alone, the providers' write-off was over $15,000.00. If I didn't have insurance, I would have been responsible for something like $22,000.00. The insurance company, however, is only billed around $7000.00. It is nothing but a travesty that the uninsured has to pay 78% MORE than insurance companies.

There’s more …

Recently I had to file a claim for the rental of a wheelchair for the brief, non-ambulatory period immediately after the surgery. As always, I spoke to the insurance company beforehand to make sure there was nothing I had to get pre-approved. Unfortunately between the time of that phone call and when I actually rented the chair, my insurance company was taken over by CIGNA. Sigh. My first explanation of benefits stated that the service was denied because the code sent in was for a cushion, not a chair. I did a bit of research and offered to fax them a copy of the page of the medical coding book that shows the code is indeed for a wheelchair. They responded that this was a service that required pre-certification (see above comment) and so I then informed them of my previous conversation including date and the name of the person I spoke with, in which I was assured that the service DIDN’T require pre-certification. Their response was that it then had to be reviewed for medical necessity (apparently to stem the frivolous rental of wheelchairs, no doubt a source of great health insurance waste). So, I helpfully mentioned that they have records showing they paid for a surgery to remove part of my collar bone and shoulder bone, thus excluding the option of using crutches, as well as the recent foot surgery causing the need.

Recently, I received two letters stating that the service had been approved. Yet, no payment was forthcoming. In a phone call yesterday, I was informed that the claim was in medical review. I offered to fax them one of the approvals I had received but they declined.

And so it goes


One last thing. The wheelchair rental cost a little over one hundred dollars. This thing, (post-surgical boot):

Cost $399.00...!?!?!? I feel like I could have made that with duck tape and some two-by fours.

Why I’m for Tort Reform or, Can We Get to the Point Already?

It’s no secret that I have a chronic health condition, Psoriatic Arthritis, which is a form of rheumatoid arthritis, a sometimes debilitating disease. The twenty-seven years of my life (which equals the entirety of my adult life) that I’ve been dealing with this has given me a pretty wide reference of the healthcare industry from the patient’s perspective. My conclusion? We got a issue in America! I will share just one (of many) unnecessary health odysseys I’ve been forced to endure to illustrate how tort reform can save money.

A few facts to keep in mind: 1. I have very good health insurance. This fact is crucial. No way would this have gone on if I were uninsured. 2. There are two symptoms of our healthcare industry’s malaise at work here: the fear of lawsuits and the lack of focus of doctors which I feel is a result of the over scheduling of patients in an effort to deal with the costs of out of control malpractice expenses. I’m actually being generous here because I refuse to believe that so many doctors that, incidentally, enjoy very good reputations, can be so incompetent.

Here’s the deal: About a year and a half ago, I started to experience the strange sensation of what felt like electric shocks coursing through my feet and legs. Please note that, while I may seem like a physical wreck, every single health issue I have can be traced back to the arthritis and its treatment-by all other standards, I am actually glowingly healthy. I was pretty sure this wasn’t an issue with circulation.

So, trying to get this over with quickly, I made an appointment with a neurologist with my chief, actually my only, complaint being that of these, while not painful, unbelievably annoying sensations in my legs. After examining me, he sends me for a full blood work-up and a cervical MRI. This is an MRI of the neck. I did not mention any problems with my neck but apparently the physical exam showed some kind of issue- I have learned it is not to one’s advantage to question a doctor without hard evidence in hand …sometimes not even then. I have to perform this fragile dance around doctor’s egos all the time in my epic quest to avoid permanent disability. So, the MRI comes back, and the doctor tells me that while there is damage in my cervical vertebrae it’s not of an unusual amount considering the underlying arthritis and oh….my blood tests were totally normal. So I ask say, “Ok…so then, what about my legs?” He answers, “What? What about your legs? “

So I go to my orthopedic office, which is probably where I should have started, and the spine surgeon there sends me for a lumbar MRI (MRI of the lower back). The lumbar MRI shows compression of the L5 nerve root (and curiously, a healed fracture somewhere else in the spine). The orthopedic surgeon goes on to spell out the steps of treatment, the first of which is to undergo injections into the spine, (these injections being the sort that require general anesthesia, one of my biggest and perhaps irrational fears). These are to address the pain, he tells me but if they cannot alleviate the pain or if I begin to have neurological symptoms then the only solution is surgery. The man is looking right into my eyes as I tell him, “I am not in pain. There is no pain. My only symptoms are neurological.” He then responds by saying, “Ok then, let’s get you scheduled for those injections.” This, by the way, is one of the official orthopedic doctors of the New York Jets (which, actually, may explain a lot). So, my response was, “Yeah. OK, I’ll get right on that.”

My rheumatologist (I have far, far too many doctor/patient relationships) has told me before, “Unless you’re completely incapacitated, or have a one hundred percent guarantee of success, do not ever let a surgeon touch your back or neck.” This seems like good advice.

So, a little while after this, I am going over all the results with my primary care physician. She is reading the blood test results when she declares, “Well, here we are!” and shows me on the print-out where it says that the level of Vitamin B-12 is such that …’the patient may be experiencing neurological symptoms such as a ‘pins and needles’ or ‘electric shock’ sensations in their extremities”, caused by malabsorption. Whadya know. This is then followed by yet another series of tests (more blood tests, B-12 injections, abdominal sonogram and upper endoscopy) to determine the cause of the malabsorption. Finally…turns out taking 800 mg of ibuprofen for 25 years can be a little hard on the stomach (a part of my medical history, by the way, that all of my doctors were aware of…assuming they were listening or actually read the my chart), and this has caused an otherwise symptomless stomach issue that resulted in my stomach’s inability to absorb B12 (and, ironically, calcium). Problem solved.

Grand total in healthcare costs? $6525.70. Amount in healthcare costs that were actually necessary? $3922.80. Overkill amount? $2602.90 This, of course, is not taking into account the paid and unpaid time off work that all this testing required and not even beginning to put a price on the level of my stress and frustration.

Keep in mind this is just ONE of my less than stellar experiences with the healthcare industry. Thank God that arthritis is not (immediately) fatal or, apparently, I would have died a long time ago.

Best healthcare in the world. Indeed.

My point is that obviously unnecessary tests are routinely prescribed and they cost us all a bundle of money. Furthermore, it has been my experience over and over again that after having ordered outrageously expensive diagnostic testing, very rarely does the doctor seem to actually read the results. What’s the damn point? This is why I am so adamant about the need for healthcare reform. I have so many more examples like this; it’s hard to avoid becoming depressed (which would, of course, engender even more healthcare costs). And ironically, I am one of the lucky ones. What if my chronic condition had a more directly fatal consequence? What if I had NO insurance? I do think that Tort reform would go a long way in eliminating the practice of this kind of medicine. Also, doctors obviously need more time to spend with individual patients when one is finding that test results are not even carefully analyzed, if at all.