Healthcare story
The year after my son Robert was born, Bonnie went back to work. She's a licensed optician, but she decided to opt for a job that provided a bit better wage and more regular hours than retail can provide, so she went to work for U.S. Healthcare, a managed healthcare organization that's since been acquired by Aetna. Bonnie detested it -- she interacted all day long with doctor's offices, wrestling over paperwork and coverage limitations. Soon enough she was pregnant with Emmeline and became a stay-at-home mom for good. But as it's turned out, Bonnie's year working for an HMO was one of the best things that ever could have happened to us as a couple, because that experience, combined with her natural frugality, has saved us thousands of dollars over the years.
Right now our medical insurance is through a CIGNA Preferred Provider Organization (PPO) plan. The plan requires a fair amount of diligence on our part to make sure the doctors and specialists we visit are in-network, but for the most part, our coverage is very good and very generous -- one of the best plans we've ever been on, in fact. But that doesn't stop paperwork problems, not by a long shot. Most of the time, it's someone in the doctor's billing office who doesn't know what the hell they're doing. Sometimes, it's the insurance company misinterpreting what procedures are being submitted for coverage, and either rejecting the claim outright or paying less than they should.
Case in point was the forty minutes Bonnie spent on the phone with CIGNA this morning straightening out two separate bills -- one for services she received last December as an evaulation for some fairly significant internal surgery that she's elected to postpone, and another for an eye exam that my younger son James received from a pediatric opthalmologist. In total, we're talking about $600 worth of bills that we were being asked to pay, even though our coverage should have only required the customary $15 co-payment we usually make.
The bigger nut -- almost $400 worth -- was the result of repeated errors made by Brigham & Women's Hospital in Boston. We've been arm-wrestling with them for over $1,200 in charges for a consultation that couldn't have lasted longer than 45 minutes.
Interestingly, during the consultation, the specialist that Bonnie met with heavily recommended that if she proceed with the surgery, she make arrangements to do so through his other office at Newton-Wellesley Hospital. As it turns out, Brigham and Women's damnably incompetent billing department is part of the reason why, and a definite assurance that we won't be dealing with them, ever, for anything, given the choice.
Anyway, long story short, Bonnie finally got it worked out with CIGNA this morning -- and while B&W really should be forced to resubmit the claim at gunpoint with a letter of apology written in the blood of the offending parties, CIGNA finally decided to call uncle and fix the claim and pay the remainder itself, realizing there's just some mouth-breathing troglodyte at B&W that's just never going to get it right.
In the other case, we were getting goosed for about $200 from the insurance company for an eye exam for James, requested by our pediatrician after he failed an eye exam during his yearly checkup. The insurance company told us that routine eye exams aren't covered under our medical plan (we have a separate vision plan that covers that). Once Bonnie explained to them that there wasn't anything routine about this exam (and James' eyes are fine, by the way), they likewise agreed to pay the bill.
So, happy endings in both cases -- but only because Bonnie had the time, knowledge and perseverance to actually make sure that the doctor's offices and the insurance company are working on the same page, and because she's capable of speaking in a vocabulary and in level-headed tones that the claims representatives at CIGNA can readily understand and interpret -- Lord only knows that I'd be seething and rabid after about two minutes of this crap.
Every time something like this happens, Bonnie and I openly wonder how much money the insurance companies and doctor's offices make off patients that just don't have the time or the resources to really look at the paperwork to figure out what's going on here and would rather just write the check than be bothered.
It certainly makes the idea of socialized medicine appealing on one level -- that the government can just take care of this itself. And every time I tell these stories, my Canadian friends just shake their heads and cluck their tongues at our backwards capitalist ways. But as much as I hate corporate bureaucracy, I can't help but feel that government bureaucracy is equally if not more loathsome, and I suspect that I'd lose some of the benefits I enjoy now if I do.
Ultimately, I'm just grateful that my wife can watch our backs so we don't get taken advantage of with the system we have now. The devil you know is better than the devil you don't know, after all.
Comments
I've often thought that there should be a huge market for "Healthcare Expediters" in this country. I'm one of those people who too often will pay a bill that may be questionable because I find the prospect of contesting it too daunting or too confusing.
If/when I have a major illness I'd be more than happy to pay somebody like Bonnie to handle the inevitable yelling at the hospital and insurance company.
If I don't do a good job of keeping on top of that stuff when I'm healthy, the liklihood of my doing it when I'm seriously ill is pretty slim. And I think there are a lot of people like me out there.
Posted by: Colin | June 28, 2004 11:39 AM
These people you are looking for are called lawyers.
Posted by: FC | June 28, 2004 03:00 PM