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.
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