Saturday, November 12, 2011

The Diagnosis

Let me preface this post by saying that I am grateful to have health insurance.  In an abstract sense, I am grateful to have health insurance.  In a theoretical sense, I am grateful to have health insurance.  But I have to be honest, in practice, 90% of the time that I actually NEED health insurance, I wonder if being indebted to doctors for the rest of my life wouldn't be a little bit worth it.

We currently use a company called Assurant Health (part of Key Benefit Administrators, a participant in the PHCS health network.)  They have terrible customer service, and their claims department may be staffed by semi-literate monkeys  people who just don't care.

(But monkeys like to throw poo, and when I get my "claim summary" each month, I feel like someone just threw poo at me.)

The first time I was seen by a doctor after enrolling in health care benefits from Assurant Health (part of Key Benefit Administrators, a participant in the PHCS health network), I was informed that I would have a co-pay of $35, and everything else would be covered.  This was in September 2010.  Two months later, I get a bill from the doctor AND from the lab who did my blood tests.  The doctor bill we paid (because I did not yet know any better), but the lab bill was $1,500.

$1,500.


FIFTEEN HUNDRED DOLLARS.


Seriously?

I called Assurant Health (part of Key Benefit Administrators, a participant in the PHCS health network), who informed me that the bill would be re-processed and paid, and that I didn't need to worry about it.  Just to be safe, I called the billing department for the lab, and they agreed to put a 30 day hold on the account, so that they could process the insurance payment.

Two months later, I get another bill.  With penalty and interest.  Assurant Health (part of Key Benefit Administrators, a participant in the PHCS health network), was still processing.

Which happened again.

And again.

Until the bill finally got paid in April. How many months is that?  1, 2, 3, 4, 5, 6, six, SIX months after I was seen (and after being harassed repeatedly because Assurant Health (part of Key Benefit Administrators, a participant in the PHCS health network), couldn't figure out how to pay the bill), Assurant Health (part of Key Benefit Administrators, a participant in the PHCS health network), finally paid it.
               
                 At a discount rate.

                                  Of $400.
??????

Okay, you know what?  Whatever, it got paid, and all I had to suffer was a few heart attacks at being presented with an unexpected bill and the precious time that I will never get back that I spent on the phone with Assurant Health (part of Key Benefit Administrators, a participant in the PHCS health network).

And yeah, I got really sick this year and couldn't be seen because Assurant Health (part of Key Benefit Administrators, a participant in the PHCS health network), mistakenly denied the doctor's visit for being out of network, and since it was a pay-up-front kinda place (yay urgent treatment), they wanted me to pay $200.

Which I didn't have.

So I had to wait until Monday, at which point I was incredibly sick and ended up missing a day of work because I couldn't get treatment on the weekend.

And yes, I have had to call them multiple times because they (Assurant Health (part of Key Benefit Administrators, a participant in the PHCS health network)) keep trying to claim The Hubs doctors visits were out of network.  (I don't think I need to remind YOU of his health issues, you faithful reader of ye olde blog, you!  But if you need the reminder, go read my blog from a couple of weeks ago.)

And sure, they (Assurant Health (part of Key Benefit Administrators, a participant in the PHCS health network)) have initially denied every single claim this year.

And yes, almost all the claims have ultimately been paid.

BUT.

There is still The Diagnosis.

See, I have an ongoing issue in my life that causes me to feel a great deal of anxiety.  And since its no secret that anxiety is kind of my biggest struggle, I can tell you that this ongoing issue resulted in significant physical illness.  So I went to the doctor, they prescribed a multitude of medications to deal with my physical ailments, and I went on. I've been monitored by the doctor, and things are under control and I am in a good place, in spite of the ongoing situation.

So, imagine my surprise when I get a bill from my doctor for the full amount of one of my follow-up doctor visits.  Of course my initial was that Assurant Health (part of Key Benefit Administrators, a participant in the PHCS health network), was simply up to their normal tricks.  I pretty much expected it.  I called the insurance company, and got some run around about the way the doctor billed the visit being not covered.

I thought this was strange, because my insurance summary CLEARLY states that office visits with my primary care provider (pcp) are covered with just a $20 copay.  So I called the doctor's office to find out what was going on.  The girl in billing looked at the bill, and looked at the denial and said, "well, that's weird.  They are denying because you received a diagnosis."

I.... what?  You can go to the doctor... but not be diagnosed with anything?  Isn't that kind of the natural result of a doctor's visit?  Feel sick, get diagnosed, get treated?  If you aren't allowed to be diagnosed, why would you go?

So, I called the insurance (Assurant Health (part of Key Benefit Administrators, a participant in the PHCS health network)) company back.

"Why wasn't this visit covered?"
"Because of The Diagnosis."
"What diagnosis?"
"I can't tell you."
"What?"
"I am not permitted to discuss The Diagnosis."
"I..but... what?  So, you can deny my claim, but can't tell me why?"
"I am not permitted to discuss The Diagnosis."
"I hear what you are saying, but I need you to explain to me why being diagnosed by my doctor means this isn't covered."
"It was because you were diagnosed."
"So, if I go to the doctor, and get a diagnosis, it isn't covered?"
"I can't discuss The Diagnosis."

Now, I have to admit, at this point, I was getting a little frustrated, and I started being a little impatient with her.

"Okay, but I need to know why this wasn't covered.  It should be covered.  My insurance summary says it should be covered."
"Well, I have to check with the doctor.  Its because of  what the doctor submitted."
"I just spoke to the doctors office.  They don't understand why you denied it either."
"Please hold while I contact the doctor's office."

*insert five minutes of horrible hold music here*

"The doctor's office confirmed The Diagnosis."
"What?"
"If they wish to resubmit, they will have to submit a statement of why it is different this time."
"How can we fix it if you won't tell us what is wrong with it?"
"I am not permitted to discuss The Diagnosis."

*I take a deep breath*

"Okay, diagnosis aside.  My benefit summary says primary office visits are covered."
"But not if you receive The Diagnosis."
"..."
"I am not permitted to discuss The Diagnosis."
"WHY ARE YOU DENYING A CLAIM THAT IS COVERED?"
"Perhaps if you looked somewhere else on the benefit summary?"
"What?"
"Maybe it discusses it elsewhere."

*This begins a long and prolonged discussion of what in the heck she is talking about, where she in a roundabout and meandering way causes me to read every section of the benefit summary until I get to the last one and she says...*

"Perhaps that applies."
"Are you kidding me?  How does this apply???"
"I am not permitted to discuss The Diagnosis."

*I spend a few minutes trying to get her to explain why this particular section applied, and eventually give up.*

"You know what?  Fine.  Please tell whoever is in charge that you were just speaking with one of the people responsible for making health care provider decisions for the entire company, and that we will now be seeking other care."

*click*

Yes.  They decided that my doctor's visit is considered outpatient mental health services.

You know what, Assurant Health (part of Key Benefit Administrators, a participant in the PHCS health network)?  Talking to you makes me think I need outpatient mental health services.  But going to my PCP, and being seen by her nurse practioner, for having an erratic heart beat and unusual pain that are ultimately determined to be related to anxiety is not outpatient mental health services.

Its called going to your doctor.

5 comments:

  1. Kerry6:39 AM

    O_O You have GOT to be kidding me. That is absolutely ridiculous!! You should definitely write them a letter and send them a copy of your blog post. Idiotic, brain-numbing bull nonsense. Whew! You guys should live in Australia. We have medicare that everyone is covered under. :D And when you go to a doctor, you are entitled to a rebate.

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  2. Oh, its covered... Under the deductible. I just have a stupid insurance company. (And i like my 15% tax rate!)

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  3. hello Google. :)

    morons.

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  4. *JAW DROP* OMG! Are you telling me, first of all, that Assurant consider anxiety a MENTAL HEALTH issue and therefore won't cover it? WTH? And wow that conversation... smh. You should seriously consider switching companies, but by all means read all the fine print.

    Health insurance is a racket. They pay your bill for 1/4 or the cost, first of all, then think they have the nerve to cover what they want but not what you need. AND they turn a profit. HUGE profits. I am all for people making money and being successful (duh!) but what they do is outrageous by the best definitions. *sigh* good luck!

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  5. Jaguwar-

    Its through my employer, and my only option ATM. But I've spent a lot of time talking options with our insurance agent, and I'm pretty sure we are switching to Carefirst Jan. 1, as long as I can get enough of my employees to enroll (have to get 51!). The whole situation is ridiculous, but I hope that by posting about it, it might stop someone else from having to deal with their nonsense.

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