when dealing with health insurance reps is bad for your health

In ALL, ILLNESS by Stephanie Klein50 Comments

Phil handles our health insurance, a nettlesome task for those with the patience of a pee-wee coach. I’m learning that health insurance is a maze with a mantra that begins, “How can we try to not provide you with our sub par service today, Ma’am?”

Our health insurance wouldn’t pay the hospital for the emergency hydrocephalus surgery Lucas needed unless we proved it wasn’t a “preexisting condition.” Calls (yes, plural) were made, explaining that Lucas’s condition couldn’t have been preexisting because he wasn’t preexisting. He’d been covered under the same insurance since the day he was born. All of Phil’s reasoning fell on deaf ears. If I bought insurance from Insurance 4 MotorTrade on a brand new car, would it be possible that it had a preexisting condition? Another time they wouldn’t pay other bills unless we proved Lucas’s condition wasn’t caused by someone else. Can you even cause hydrocephalus? The latest healthcare marathon in our home involves Lucas’s pediatric neurosurgeon.

He has treated Lucas with such care, and has navigated all the unknowns regarding hydrocephalus, infection, and the enhancements of Lucas’s spine. There is only one pediatric neurosurgeon in Austin, Texas, and thankfully he is in our “network”. At least he was until a month ago. Now that Lucas needs to go back for his six-month MRI, we’ve discovered that he’s no longer in the network. Our friends suggested we switch to One Sure Insurance, but after so many years with our current provider we felt like we would just run into more problems if we switched so late in the game. Common sense would dictate that if the health insurance network cannot provide an alternative to the only pediatric neurosurgeon within 200 miles–and someone who has provided continual care and monitoring of an infant with a delicate condition–that they’d at least have an authorization process in place. So, Phil inquired and was told there were authorization steps to be taken. The doctor’s office, however, was told there were not. Conference calls were made.

“Have Lucas go to the neurosurgeon and when the bill comes appeal it,” advised the health insurance rep on the phone.  Yeah, how do you think that one is gonna work out? The good news? Since Lucas’s last MRI (which looked totally clear), we won’t need to go for another follow-up until a year from now. Man, I miss that little guy. Before I know it, though, I’ll be home.

Comments

  1. CRAZYPANTS.

    "How can we try to not provide you with our sub par service today, Ma'am?" seems pretty on track to me. i think it is the subliminal message to that "Your call is very important to us" B.S. that they repeat over and over while you are on hold.

  2. Incredible! Phil must be a saint. Reading MOOSE and you are hilarious!

  3. Health insurance companies are the worst. I've had similar experiences. Glad you have Phil.

    By the by, just read Straight Up and Dirty and nearly pissed myself with the Oliver and bathroom scene. Can't wait to pick up MOOSE.

  4. Saw you at your reading in L.A. last night. Loved the porn story. Me and friends going to your Pasadena event tonight.

    Moose is great(i'm at page 125)

  5. Health care is an absolute crisis in this country. It affects us all (in the form of sub par care and inflated premiums). My heart goes out to you, and everyone else struggling in the health care maze.

    Here's to hoping our next President can do something about it!

  6. Is there anything more sinister than having to beg for your health? Man this gets me riled up. At least I have health insurance(as feeble as it is). Can I hire Phil out?

  7. Making sure you get reimbursed for medical care is a job within itself. At least Phil keeps on them. Most people get tired of it and just pay. I think they bank on that. The plan my company has is terrible. One of my coworkers didn't call the main office before getting EMERGENCY TREATMENT, so they would only cover part of it. Because most of us have fair warning before going to the emergency room.

    Moose was so good. I loved Straight Up and Dirty too, but there is something about Moose. I couldn't put it down. Kate sounds like the best friend to have. What a riot. "You may have noticed I have a slight weight problem." I was laughing out loud at that. It helped to balance out the sad parts.

  8. I had a similar experience with muy son. i assume I'll have a similar experience with my mother in 10 years.

    My copy of MOOSE is on the way from Amazon!

  9. After hearing you speak in Chicago. I was one of the lucky few that didn't get turned away because the room was too small for the crowd. I think you should do an audio book or radio. You are great!

  10. You sure hit a sore spot with me. I've found that for anything besides routine preventive care appointments, the insurance company will try to screw with you. There is always a fight involved to get them to pay their share. I believe it is part of their business model–just deny part of the claim and see if the insured protests. If they do, then give them a different reason everytime they call and put them on hold forever, tell them you'll call them back and never do, send statements that are impossible to decipher. Eventually they'll go away. While it infuriates me, I won't give in. I call and call and write letters and argue and I usually (eventually) win (and that's only because I'm arguing over relatively small claims.) But how many people have the time, the confidence, the tenacity and the advanced math skills it takes to figure out their stupid billing? Most people just pay or if they can't afford to, let it ruin their credit. I'm lucky to have insurance but it is a scam.

  11. I recommend Michael Moore's film Sicko, which examines exactly this awful issue – health insurance companies' evasion of responsibility in paying for patients whose claims are obviously valid.

  12. Yup. Insurance is F.U.N. I sure miss the good old days when you sent your bills in and the person at the other end actually believed the doctor when told 'yes, surgery to repair a complete bilateral cleft lip and palate IS necessary.' We've been dealing with that garbage since the day my twins were born, actually, since my oldest was born. N.O.N.E. of his doctors are in network. My life has been a series of calls, letters, appeals. Perhaps you can ask for a complex care case manager? I believe one HAS to be provided once you ask for one, that way there is one person to whom you can direct your calls. Not that it does a lot of good because really, insurance companies are out to make as much money as possible regardless of who pays the price. This is a subject that just riles me. My husband's family owns the business for which he works so we're fortunate that we have insurance that "allows" us to go out of network. The cost is completely astronomical and honestly, so far, we probably could have SAVED the money and invested it for what it costs us and have less aggravation, fights, denials and burdens-of-proof. It's insane. I'm so tired of telling morons at the other end of the phone that my son was born with the genetic equivalent of a bomb blowing up in his face… IT IS NOT COSMETIC!!!! It is unreal. Here's hoping for Lucas' continued progress, dealing with the insurance alone is enough to put one on blood-pressure meds.

  13. I completely understand your frustration with insurance companies. A couple of years ago I was sick for months with something they could not diagnose and was fighting with the insurance company the whole time I could barely get out of bed. You are lucky to have Phil on your side.

    btw- was at the LA reading last night. I knew I would like you but what struck me the most was how down to earth you and Phil were. You really seemed like good, salt of the earth, type people. You seem like such a straight forward, no bs person. A little sarcastic and extremely witty, you are my kind of people. oh and your wedding ring is gorgeous! What type of cut is your engagement ring? it was stunning!

  14. My mom has wonderful medical insurance through her Union which covers my expenses and provides quality healthcare until i graduate college. However, I am still getting a $400 bill from when I had to go to the emergency room on a Saturday. I mention the Saturday part because had it been on a weekday I would've been able to go to the Urgent Care at the Union's clinic. But I'm so unlucky I had to get sick on a weekend and my only option was the emergency room.

    The Union/insurace people can't pay for the bill because they found out the bill was for $900 and they already covered all the procedures and paid the doctor…the other $400 was the rest of the doctor's fee which they say they can't cover because that is not what they pay our doctors.

    So my only other alternative is to call the hospital and beg them to waive the fee because I am a student. ughhhhh. $400 when I barely saw the doctor and was just hanging out in a room by myself until the test results got back.

  15. I'm so looking forward to your reading tonight in Pasadena. Loved Straight Up and Dirty so much I gave it as bridesmaid's gifts. ironic, huh?

  16. Insurance companies suck moose cock, no pun intended re: book title.

    When Phil finally deals with someone who is responsive and respectful, tell him to get the name and deal only with that person. It's easier and more consistent. Until then, suggest that he keep a log of the people with whom he speaks and what they said. You gotta' love erroneous info that ends up costing you.

    It's utterly amazing that we have to pay huge premiums, which merely allow us to walk into a doctor's office within our network. Once there, we have to probe to learn if we're getting the right treatment, or an HMO approved treatment. Because some moron at a desk really knows what we need.

    I *only* go with plans that allow me to go out of network. Yes, it costs more, but I'll be damned is some anonymous yahoo is going to make decisions about my medical needs. Thank you very much, but I'll choose my own doc, and I'll go to their referrals. There's just a limit to how paternalistic this society can become. Or there should be a limit. (I have to put out my cigarette now. Someone 40 blocks away is complaining about my second hand smoke.)

    Great news about Lucas!

  17. I had go-round after go-round with the first and only time that I had an HMO. I was living in Los Angeles and my primary care providor wouldn't give me a referral for a Neurosurgeon! Finally, my Neurosurgeon had to threaten my insurance company and PCP with a lawsuit just to get a referral. There is a special place in hell for the people that run insurance companies.

  18. It was great to meet you in Chicago. You were amazing! Thanks for your insight and humor…defintely a great way to spend a little time away from my kids!

  19. Insurance, any type, is great until something actually happens. Then, like magic, they don't care about you anymore. Just ask some of those Hurricane Katrina victims.

  20. Hi Stephanie, sorry to hear about the insurance woes! You might want to ask if your insurance company can assign a case manager for you– this person would be an employee of the company, but it's their job to help you navigate the system and get you straight answers quickly. I have a friend with a very sick child (now 4) and this service has been a saving grace for her family in negotiating the in's and out's of their son's multiple surgeries and rehabilitative services. It hasn't been easy even still, but certainly has helped. Good luck!

    I am loving Moose!

  21. Yikes! I hope it gets figured out.

    And I checked and your book goes on the front table on the 13th, I think. We have 4 right now and 4 on order. We've sold 3 so far, but I'm sure that will increase once it's on the table.

  22. I could go on and on about this, but I'll stay off the soapbox except to say that it's even worse (if possible) for mental health. Yeah, THAT helps decrease the stigma…

    Wishing I could attend your event tonight, but am stuck in class. Best of luck!

  23. Steph, is it Dr. George's office? At Strictly Pediatrics? He's my favorite doctor that we visit. We've had no surgery, but my son had a Grade IV/Grade III bleed at birth and defnitely has some challenges. We love Nicole Higginbotham his Nurse Prac.and they have been really helpful with regards to referrals, how to ensure things get covered, etc. We are having trouble getting additional therapy, but all the docs swear that it just takes a little endurance, and some homework. Do you have a case manager @ your insurance company? We have one who is actually (allegedly) helping us get things covered. Y'all should have one since you had twin preemies. Good luck with this and let me know if you want to trade notes on docs/therapists/resources. I bet we're running into the same people!

  24. "explaining that Lucas's condition couldn't have been preexisting because he wasn't preexisting."
    great point!

    insurance companies suck big time so i totally feel your pain. Often it is the case that it will take a written letter from the doctor to correct the problem. Definitely have the doc put something in writing and fax it over to your insurance company. I have had prescriptions not covered and then the doc writes a letter that they were medically necessary and bam they were covered.

  25. When my twins were born, the hospital billed everything as 'baby weiss' so all of baby 'b's claims were denied. They were in the NICU for almost 6 weeks. Every claim was denied. It was a mess! I just kept hanging up until I found someone competent.

  26. I am not sure of Phil's work situation – is your health insurance provided by his company or do you have it personally? If it is provided by a company – then get your benefits person involved. They can often help out in these situations. Just a suggestion

  27. That "pre-existing condition" clause is pure and utter bullshit!!! I hate health care companies. I once was offered a job at a health care company – I couldn't take the job – it would have felt too much like selling my soul.

  28. I'm fairly certain that the person on the other end of the line is trained to make your day as bad as it can possibly be.

    I had to appeal a $32K bill for an "out of network" provider even though I had a pre-authorization number. It was denied. Apparently, even though a medical event is pre-authorized, they don't have to pay for it if it's outside their ever-changing boundaries.

    And since I don't happen to have $32K….I will probably never own a house. So, yeah, they suck.

  29. In my experience, insurance companies suck! It's so nice to hear that Lucas is doing well, and before you know it, you'll be back home. I hope your book tour has been going as well as you had hoped. It was great meeting you in Manhasset, and I found you incredibly entertaining and thought provoking.

    Totally off topic, I was wondering if Jen Lancaster did the honorable thing and went to your book reading in Chicago, especially after you proved what a class act you were by going to her reading and then writing such a nice post afterwards. I happen to like her books and would hope that she had enough class to do the right thing too. If not, I guess it shows who the bigger person is. Absolutely NO pun intended.

  30. I agree wholeheartedly about the sentiments expressed about health insurance companies. The ironic thing is that for those of us who are lucky enough to have health insurance, there are still so many who don't. I cannot even imagine what that would be like and to have some sort of illness.
    Also, for couples like Phil and Stephanie, who are (and I am only assuming here) comfortably wealthy, who still have have to battle the insurance companies, imagine what it is like for people who make far less and who don't have the skills necessary?
    I don't get how people are health care reform. Truly.

  31. I once had a $22,000 surgery that was pre-authorised, and supposed to only cost me a $300 co-pay. Two months later, I get a $3000 bill. Apparently there was both an anesthesiologist and a nurse anest. in the operating room, and the insurance company refused to pay for both. I fought it for 6 months and eventually the hospital ate the cost.
    Another time I was prescribed a medication that the insurance company would only approve an 11 day supply of, forcing me to return to the pharmacy 3 times a month, paying the co-pay each time.
    Unfortunately this won't get any better until the companies are drivin out of business by a lack of people who can afford insurance. Most political/government plans to fix this still keep insurance companies profitable and "in the game," thanks to lobbyists, and will end up costing everyone more.

  32. When my son was born, the hospital would not circumcise him – they said it had to be done in the doctor's office. Took him to the doctor's office where I was told that insurance would not cover it because it wasn't done in the hospital. It was now considered "cosmetic" (why isn't it always considered cosmetic??).

  33. Our insurance's standard protocol when they receive a bill. DENY EVERYTHING. Mail a form to the insured to make sure it was not the result of a car accident or worker's comp claim.

    Frankly, we grew weary of all the f-ing forms…which is exactly what they wanted. They quit paying my bills.

    Let's see, my incarcerated ventral hernia requiring repair with mesh, the impending 9 months of intense pain control, the 24-day hospitalization 1-month after the surgery due to a rather large DVT and 15 pulmonary emboli…yes, all caused by either a car accident AND an accident at work.

    I hate them with a un-holy passion.

  34. Wow, that's something I'll be tackling in about a month myself. I'm Canadian, but getting married in July and San Diego is now home. 6 months ago I had a horrible car accident and now have MANY preexisting conditions. Multiple fractures and a bad head/brain injury. When does an injury that heals stop being a preexisting condition? Geez. I'm going to hang on to my Canadian health card for as long as possible. At least all the care I got there was free, and REALLY good. If it had happened here, we'd be bankrupt for sure.

  35. I have been quoted as saying that Insurance companies are Satannn!(Think SNL church-lady) I won't go into details, but with my husband's cancer treatments, we have seen first hand how evil medical insurance companies can be. To me it's like adding insult to injury. You go through something like a health crisis, that can leave you feeling on the brink of disaster, to having to fight for the very coverage you have already paid for!

    I'm glad that things with Lucas are going well under the circumstances! And feel for both you and Phil on the insurance battles.

    Like you, my husband Paul, handles the insurance company. Except right now, it's his medical crisis, and yet he has to fight for the payment of his treatments. (Yes, I feel guilty about that. But he's been doing this for so long, he knows better how to navigate the red tape) Spewing swear words at some idiot answering the phones rarely gets you the desired response. (I don't have the patience for it)

    Glad your book tour is going well Stephanie. And that you'll get to be with Lucas and Abigail, at home, in your routine soon.

    3T

  36. This brought back nightmare memories of dealing with insurance companies over my three kids' asthma. I had to call them about every explanation of benefit – they couldn't do the math correctly! At one point I told them I was going to send them an invoice for my time since I was doing their work for them.
    Anyway, my sympathies and prayers to all of you. Tell Phil to hang in there.

  37. i have so been there. i have endometriosis and have had three surgeries in a few years, medical treatment, diagnosis, testing, blah, and the insurance sucked sucked sucked.

    hang in there.

    i love your blog. i'm new to blogsphere and added you :)

  38. I have a bad knee and was given a cortisone shot in the hopes of relieving some of the pain. When I got the bill I was told it was listed as a 'Surgery" A SURGERY" I got F#@#N SHOT FOR GOD'S SAKE NOT A APPENDECTOMY.

    I'm appealing it and will not quit. I unbelievable. I'm sorry to hear you have to got through and I agree, anyone on the board of directors and the major shareholders of any of these companies should absolutely rot in hell

  39. Wow. Come to Canada where they at least have compassion (and universal health care). Unreal.

  40. the first thing you need when you get sick isn't a doctor. it's a spreadsheet and a secretary and a lawyer.

    my stomach turns as soon as i hear the hearty "welcome" on the 800 #, followed by an admonition to "please listen carefully, as our menu options have changed."

  41. I have a wife with MS and have had this battle almost montly with her doctor….seriously if you all need help beating some sense into the insurance company let me know. My most recent event with insurance is they considered dropping coverage on a sustaining med for the wife….I convinced them that dropping that med (retail cost is $2000.00 per month-thank god the copay is only 30) is stupid because a relapse would cost them probably what 2 years worth of medicine would

  42. OMG! I hear you on the Customer Service theory!! Check out my blog that I wrote today: http://missdaisydog.blogspot.com/ – "Is it just me or do I need to up my medication?"

    I was actually in a BOOKSTORE wanting to purchase your book "Straight Up and Dirty" and had a pretty horrible CS experience!! Arrgghh!! Unhelpful idiots make me crazy!!

    Anyway – I can't wait to read your book and I'm soooooo mad, I'm in Chino Hills, CA (just outside of LA) and see that you were in town. Arrrggghhh again!!

    Oh well, hope you had a great trip and best of luck with the book and most importantly, Lucas.

    – Jill

  43. OMG! I hear you on the Customer Service theory!! Check out my blog that I wrote today: http://missdaisydog.blogspot.com/ – "Is it just me or do I need to up my medication?"

    I was actually in a BOOKSTORE wanting to purchase your book "Straight Up and Dirty" and had a pretty horrible CS experience!! Arrgghh!! Unhelpful idiots make me crazy!!

    Anyway – I can't wait to read your book and I'm soooooo mad, I'm in Chino Hills, CA (just outside of LA) and see that you were in town. Arrrggghhh again!!

    Oh well, hope you had a great trip and best of luck with the book and most importantly, Lucas.

    – Jill

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