Thursday, July 26, 2007

Becoming Insurance Savvy

I know nothing about insurance. Really, nothing. My crash course in how my insurance actually worked was my second day in the hospital, after having come out of a coma 24 hours before, when a woman from the hospital’s billing department called me and asked what my insurance information was. At that point, I couldn’t feel my feed and my head still felt like it was, literally, full of molasses. Luckily, Jenn had my wallet handy, and I read my information to them over the phone.

A woman with a clipboard was back the next day, while I sat in a puddle of urine from a leaking catheter and a smear of my own blood because my period has started, and said, “You do know that you have a rather high deductible. Can you pay us something right now?”

“Sure,” I said. But I think that at that point, Jenn and the wallet had left, and I was on my own, and I figured I would pay part of that to shut them the hell up as soon as I got the bill.

Because I’d never bothered to submit any of my receipts to my insurance provider. With a $2500 deductible, you just figure you’ve got exactly what I had: catastrophic insurance. Something that’s only useful if you get hit by a shovel, but everyday stuff, all of my antibiotics and gyno costs and birth control costs and the doctor’s visits, I’d just pay all of those out of pocket. I was young and invincible, so I didn’t feel I had to pay much attention to health insurance.

All that changed on May 15th of last year.

I received a $28,000 hospital bill and a slew of other, unrelated bills. The doctors who treat you aren’t actually employed by the hospital. They charge you bills in *additional* to the room and board and machine costs the hospital charges you. So there was a $600 cardiologist bill, a $500 endocrinologist bill, a $400 ambulance bill, and all these random bills for tests, lab tests, I didn’t have any idea what any of these tests were for. There were X-ray charges from when the cardiologist ordered that I get a chest X-ray because I was having trouble swallowing. The endocrinologist later figured out all I had was thrush caused by bacteria from the oxygen tube, and treated it with some $4 antibiotic that I was charged $20 for.

All of these bills were submitted to my insurance company. I had to pay my $2500 and 80% of hospital bill, but after I shelled out 6-7K or so for meds, supplies, my portion of the hospital bill and assorted 80%s of the other bills, they finally started to cover 100% of everything. I’d reached my out of pocket limit, apparently. I wasn’t aware that I had one. I thought I’d always be paying my 80% after my deductible.

With my catastrophic plan, I didn’t have to worry about a primary care doctor or in and out of network or anything like that, I figured, because what was the difference between covering 100% and covering 80% when you were shelling out $2500 a year regardless before you saw any benefit from it?

But, now.

Well, now I have another slew of insurance choices, and tricky things like choosing an “in network primary care physician,” which I’ve never bothered to do before. Why would I choose a “primary care” physician? If it was gyno related, I’d go to a gynecologist. When it was a sore throat, I’d go to a walk-in clinic.

Now I have to see the gyno, an endocrinologist every three months, a podiatrist (recommended) once a year, and the usual vision check every year, plus, of course, anything that comes up as far as complications or additions goes (sore throat, pelvic pain, bronchitis, etc). I go to the pharmacy for meds at least twice a month (I have to pick up testing strips at least that often, and I *should* be getting insulin once a month, but I keep trying to make it last longer than it should).

What this means is that I’ve finally reached the point where I finally have to fully and completely deal with America’s fucked up, confusing, incredibly inefficient and debilitating healthcare system. I have to choose something called a “primary care” physician if I want 100% of my costs to be paid, but it can’t be a truly useful primary care physician for me, like an endocrinologist. It’s going to end up being somebody who does the work of a walk-in clinic and prescribes antibiotics for sore throats.

My new endocrinologist only agreed to see me so long as I was clear that she would *not* fill the role of my primary care physician. She refused to be listed as such, even if, my some strange coincidence, the plan I was a part of had her name on it.

There are a lot of really confusing things in here, and they’re worded really awkwardly like this one under the list of “Limitations and Exclusions” for my new health plan. It says, “Unless stated otherwise, no coverage will be provided or paid for or on account of:” and number 4 is: “Prescription drugs, including insulin and syringes, vitamins, unless medically necessary for a medical condition and nonprescription drugs or medicines, except for diabetes supplies.”


I had to read this three times before I realized they weren’t saying, “We won’t cover insulin.” They were saying “we’ll only cover insulin if it’s medically necessary.”

Which is fine, but that’s a really fucked up way to phrase that, and it made me really apprehensive for about three minutes.

Why is insurance coverage so hard? This shouldn’t be rocket science. This shouldn’t be hard. If you’re sick, you should be able to get better. You should be able to choose the best way to get better; the best doctor, or the most convenient doctor. You should be able to pay your $20 co-pay for anything. Fucking *anything* and go home and get better.

These policies have been written and created to provide the least amount of care possible to the healthiest number of people possible. Which might make a lot of money for somebody else in the end, but is going to ultimately result in a lot of unhealthy and ultimately dead people who aren’t any good to anybody.

7 comments so far. What are your thoughts?

La Gringa said...

First, congratulations on getting a full-time job. :-) Awesome news!

Second, primary care physician can be a lifesaver. I have had the same one since I moved to New York City. For the first time ever in my life I have had the same internist for more than two years running. Why is this good? Because they KNOW you. They know when thnigs aren't right sometimes even before you do. You build a relationship with them and become something more than a number on an insurance claim.

And they fight your insurance company on your behalf.

I would ask around - people you trust, and see if anyone has a doctor they would recommend. I have sendt at least four people to my internist and they all love her. She actually listens to you.

If you get a good internists, he/she will be able to work in tandem with your endo and your gyno (like mine does). It can be a lifesaver.

And remember that most "in-network only" plans still cover catastrophic emergencuies outside the coverage zone.

See if your company has a health advocate in HR. They can be very helpful in answering questions.

La Gringa said...

OH, and the other thing that a good primary care physican will do is work to find ways around insurance companies idiocies re prscriptions and required tests, etc.

The whole idea of going to a PCP is that it is wellness-maintenance. You go in two or three times a year to stay healthy, not once a year after you are already sick.

My doc helped me with my nutrition plans when I wanted to lose weight and started lifting weights seriously (she even ordered me to drink red wine to make good cholesterol go up - hilarious!). I went in once with a wicked headache and she figuired out within seconds that it could be a pre-aneurysm - sent me to the next floor up to a neurologist and immediate CAT scans and MRIs - something I'd have had to wait hours for in an ER.(Luckily, it wasn't anything serious.)

The point is, you need to stop viewing doctors as your enemies. Not all of them are bad, and not all of the health care system is a mess. Take advantage of the benefits. Look into whether they have a wellness program. A wellness program will pay for things like massage and acupressure, etc, for stress reduction. (Yes, totally serious.) And some health care plans (like Oxford) will reimburse you for gym or health club expenses if you go a certain number of times in a year.

Anonymous said...

speaking as a person who used to manage the health insurance plans in the HR department of a company - yeah, insurance isn't there to make you well, per se. they are companies that try to improve returns to stokeholders, so they do everything that smart people would think to do to make that happen - kick out people who cost money (ie, the sick) and make it difficult for people to get reimbursed in the event of needing care.

one of the things i always had to weigh when considering the skyrocketing costs to premiums each year was if we decided to go with a "cheaper" plan to bring down costs, ultimately it would mean that my job would turn into full time insurance consultant for the employees, because everything would be so gd confusing. six of one, half dozen of another...

but yeah, utilize your HR rep as mch as humanly possible. plan docs don't make sense to you? ask her. if she doesn't know, then that's why she has a client rep at each insurance company, to educate and help *her*. like a good PCP, your HR rep can help fight the insurance company if they're hassling you. She is in fact their client, so they have more of a vested interest in responding to her.

good luck, sounds like things are truckin along for you, kameron!


Kameron Hurley said...

yeah, this HR Manager has been my best friend though this whole thing. We're actually changing plans August 1st, and she's doing the high/low premiums dance right now.

She's been really available to me regarding the healthcare plans, and open about the fact that they haven't decided on a new one, but she'll give me the downlow on it when they sign on the 1st.

Jennifer said...

They'll only cover insulin if it's medically necessary? Who the hell takes insulin when it isn't?!?! It's not a damn recreational drug here!

Kameron Hurley said...

yeah, that was totally my thinking when I read that: "What, they think there are people out there who take insulin shots for shits and giggles?"


Bad Decision Maker said...

ha ha. in 8th grade, I once whipped out my syringe and Regular (back in the day, no Humalog insulin) and the kid with the reputation for being a big badass druggie was like OOOH CAN I HAVE SOME??? (clearly he wasn't as badass as everyone thought if he didn't know the difference betweeen insulin and recreational drugs)

so uh, i guess the insurance companies are just protecting those adventurous 13 year olds? right....