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Tuesday, August 11, 2009

Maybe Sarah Palin thinks "death panels" are OK when they are run by giant corporations
Posted by Jill | 6:06 AM
...because that's what we have now:

-- In June 2008, Robin Beaton, a retired nurse from Waxahachie, Texas, found out she had breast cancer and needed a double mastectomy. Two days before her surgery, her insurance company, Blue Cross, flagged her chart and told the hospital they wouldn't allow the procedure to go forward until they finished an examination of five years of her medical history -- which could take three months. It turned out that a month before the cancer diagnosis, Beaton had gone to a dermatologist for acne treatment, and Blue Cross incorrectly interpreted a word on her chart to mean that the acne was precancerous.

Not long into the investigation, the insurer canceled her policy. Beaton, they said, had listed her weight incorrectly when she bought it, and had also failed to disclose that she'd once taken medicine for a heart condition -- which she hadn't been taking at the time she filled out the application. By October, thanks to an intervention from her member of Congress, Blue Cross reinstated Beaton's insurance coverage. But the tumor she had removed had grown 2 centimeters in the meantime, and she had to have her lymph nodes removed as well as her breasts amputated because of the delay.

-- In October 2008, Michael Napientak, a doorman from Clarendon Hills, Ill., went to the hospital for surgery to relieve agonizing back pain. His wife's employer's insurance provider, a subsidiary of UnitedHealthCare, had issued a pre-authorization for the operation. The operation went well. But in April, the insurer started sending notices that it wouldn't pay for the surgery, after all; the family, not the insurance provider, would be on the hook for the $148,000 the hospital charged for the procedure. Pre-authorization, the insurance company explained, didn't necessarily guarantee payment on a claim would be forthcoming. The company offered shifting explanations for why it wouldn't pay -- first, demanding proof that Napientak had tried less expensive measures to relieve his pain, and then, when he provided it, insisting that it lacked documentation for why the surgery was medically necessary. Napientak's wife, Sandie, asked her boss to help out, but with no luck. Fortunately for the Napientaks, they were able to attract the attention of a Chicago Tribune columnist before they had to figure out how to pay the six-figure bill -- once the newspaper started asking questions, the insurer suddenly decided, "based on additional information submitted," to cover the tab, after all.

-- David Denney was less than a year old when he was diagnosed in 1995 with glutaric acidemia Type 1, a rare blood disorder that left him severely brain damaged and unable to eat, walk or speak without assistance. For more than a decade, Blue Cross of California -- his parents' insurance company -- paid the $1,200 weekly cost to have a nurse care for him, giving him exercise and administering anti-seizure medication.

But in March 2006, Blue Cross told the Denney family their claims had exceeded the annual cost limit for his care. When they wrote back, objecting and pointing out that their annual limit was higher, the company changed its mind -- about the reason for the denial. The nurse's services weren't medically necessary, the insurers said. His family sued, and the case went to arbitration, as their policy allowed. California taxpayers, meanwhile, got stuck with the bill -- after years of paying their own premiums, the Denney family went on Medi-Cal, the state's Medicaid system.

-- Patricia Reilling opened an art gallery in Louisville, Ky., in 1987, and three years later took out an insurance policy for herself and her employees. Her insurance provider, Anthem Health Plans of Kentucky, wrote to her this June, telling her it was canceling her coverage -- a few days after it sent her a different letter detailing the rates to renew for another year and billing her for July.

Reilling thinks she knows the reason for the cutoff, though -- she was diagnosed with breast cancer in March 2008. That kicked off a year-long battle with Anthem. First the company refused to pay for an MRI to locate the tumors, saying her family medical history didn't indicate she was likely to have cancer. Eventually, it approved the MRI, but only after she'd undergone an additional, painful biopsy. Her doctor removed both of her breasts in April 2008. In December, she went in for reconstructive plastic surgery -- and contracted a case of MRSA, an invasive infection. In January of this year, Reilling underwent two more surgeries to deal with the MRSA infection, and she's likely to require another operation to help fix all the damage. The monthly bill for her prescription medicines -- which she says are mostly generics -- is $2,000; the doctors treating her for the MRSA infection want $280 for each appointment, now that she's lost her insurance coverage. When she appealed the decision to cancel her policy, asking if she could keep paying the premium and continue coverage until her current course of treatment ends, the insurers wrote back with yet another denial. But they did say they hoped her health improved.

You don't want a "government bureaucrat" deciding your health care? Instead you have a gum-chewer sitting in a cubicle getting paid for denying your care. This is better? Life and death decisions are somehow OK when it's a kid with a high school education making them so that an insurance company executive can take home eight figures in compensation every year?

My coverage is with Anthem. I sure as hell hope I never get sick.


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Anonymous Anonymous said...
" ... kid with a high school education ..."? Maybe an Indian high school...
I haven't spoken to an American sounding phone answerer at an insurance company since I don't know when....
I don't have Anthem. Sometime wish I did! Is their phone screening center in the US?

Anonymous Charlie O said...
I have a good job and decent health insurance. But, I know what a pain the ass the insurance companies are. I have been fighting with them in one way or another for years. My favorite is the refusing to pay claims because the provider is "Out of Network." I'm kind of anal about that stuff. I NEVER go see a provider without checking to see if they are in plan. So I know these denials are bullshit. Its a game they all play. Hoping you won't call them on it. Luckily, I have a knack for writing professional, but caustic letters to these humps pointing out their error. Every denial has eventually been paid, but the point is I shouldn't have go through this circus over and over again.

This crap about bureaucrats making your health decisions is just that, crap. It's a non starter. It's already going on every day.

We need reform now. And not a bullshit watered down version of reform. I'm all for a public option, or better yet, a single payer system. Health care needs to be severed from employment.

I'm more or less a "have" nowadays. But I remember all to well, the days when I was a "have not." I remember when I lived paycheck to paycheck. No health insurance and a tax credit would have been worthless to me to get it.

This country has turned into a population of greedy, selfish SOBs. This attitude of "I've got mine, so screw the rest of you" will be our demise. If caring about your neighbors health and/or healthcare is socialism, then bring it on. I embrace it completely.

Anonymous Anonymous said...
I have coverage with Oxford/United Health Care from my (former) job. I've had two surgeries covered by them. There were no problems with paying for the doctors and the surgery itself. A problem both times was with paying for the pathology tests of the tissue removed -- Oxford told me both times they wouldn't pay because they hadn't approved the hospital's OWN pathology lab for the procedures. Who, when planning a surgery, thinks to ask about tissue pathology and if the hospital's OWN lab is in network or not? BTW, one surgery was to remove a fatty tumor and the other to repair torn cartilage in my knee. After a letter or two, Oxford paid the pathology bills. They also had a third party company try to find a copayer on the knee surgery. The lady kept me on the phone for over 20 minutes asking if I was in a car accident (nope), did my husband have insurance (I'm not married), was it a worker's compensation case (no, no accident at work) or was I covered by my parents... She kept asking over and over. I kept telling her "no". They were stuck with covering that one by themselves.

Blogger D. said...
Um, Jill? I love you, but blaming "a gum-chewer sitting in a cubicle getting paid for denying your care" shows class bias--those decisions are made a bit further up.

Blogger Nan said...
D, I think you're engaging in wishful thinking. Nice though it might be to fantasize that the person deciding whether you live or die is some semi-competent professional, odds are the initial denials are being made at the lowest levels of the corporate food chain, not the top.

Blogger D. said...
Hi, Nan.

No, more probably I am working with a possibly out of date template. My un(der)educated (at the time) self spent three *shudder* years working at an insurance company. Admittedly not a health insurance company, because there were, at the time, barely 2; Blue Cross/Blue Shield and HIP (which I think stood for Hospital Insurance Program but don't quote me). Major Medical was separate and usually connected with Accidental Death and Dismemberment (what is it with these typoes?) and other catastrophe.

I am perfectly willing to believe that the lowest-level workers are permitted to flag stuff in the files when a claim comes in. But actual decision-making? Uh-uh. What I sometimes refer to as "guerrilla tactics for job enhancement" were first developed at the insurance job because we were not even supposed to take different lunch hours.

(Which is to say, I fully condemn the insurance industry, but blaming clerical staff is like blaming the clerk who points out that the important motion for which all parties have to show up in court has been scheduled for Yom Kippur.)

Blogger Jill said...
Sorry to chime in so late, but I can't do this during the day.

No one is claiming that the person in the headset sitting in the Initech outsourcing cube is the decision-maker. But when the right talks about "some government bureaucrat" deciding your health care, it's pretty disingenuous, given that the person in the headset was essentially hired to be a roadblock, in much the same way most help desk techs are not hired to actually solve computer problems but instead are supposed to close tickets as quickly as possible.

Most of us are never permitted to actually talk to someone who makes the decision. But they hire the person with the headset specifically to DENY COVERAGE AND DENY PAYMENTS unless the "customer" fights like hell and demands to be escalated up to someone closer to the actual decision-maker. That is their JOB, that is what they are hired to do.

Blogger casey said...
Hello Jill,

I agree that the person with the headset is not the one deciding our health care but if asked why they deny claims the party line is: "I was only obeying orders".