September 5, 2009

Rising health-care costs are all my fault

It's true. See what this "friend" wrote me some weeks ago:

Oh, so you're the guy who's driving up everyone's premiums with your insatiable demands for weekly colonoscopies.

Don't worry: the TMI in the full entry is about insurance companies, not what the doctors found.

Thanks to family medical history, my regular doctor and I had decided early this year that a colonoscopy was warranted at the tender age of 44. Not exactly fun, from everything I'd heard, but I'd rather have a day or two of inconvenience than colon cancer. So I [the details of the procedure have been redacted except for this completely accurate depiction by Dave Barry for reasons of national security; trust us on this one, you don't want to know--your neighborhood NSA guys]. No problem--benign! Okay, I'll have to return in a few years.

A few weeks later, I received an explanation-of-benefits sheet from my insurance company saying they had paid $mumbledy to the place where I had my colonoscopy. (By the way, did you know that March is Colonoscopy Awareness Month? I always wondered why that's the first half of the regular Florida legislative session.) Okay, I thought: that's the facility. What about the doctors?

No problem! A few weeks later I received another explanation-of-benefits sheet, with no payment to the GI. None. Zip. "You're too young to know," was the explanation at the bottom. No, it wasn't: they said that they wouldn't cover preventive colon care before I was 50. A few days later, another nonexplanation of nonpayment, this time to the anesthesiologist.

Puzzled, I called my insurer. The explanation: "The diagnosis code does not fit with an allowable expense." I suspect the real explanation was three times as wordy and I have shortened it as a result of the lasting mental trauma I experienced. I explained in response: I've got a family history that justifies a colonoscopy. "The diagnosis code does not fit with an allowable expense, and you've got an ugly nose, too." I explained a little more: not only did I have a family history, but the GI removed a polyp. How could it be unnecessary if they found something? "The diagnosis code does not fit with an allowable expense, you've got an ugly nose, and your sister's one, too." I explained further: not only did I have a family history and the GI removed a polyp, but the insurance company had paid for the facilities charge. "Oh, yeah, and see if your doctor can change the diagnosis code."

Well, that went over like a ton of Rush Limbaugh with the accounting department in the medical group. "So they're asking us to commit fraud?" was the response. We talked for a few minutes, commiserated, and then I sent in an appeal to the insurer. I explained that few people volunteer for colonoscopies, I sent a copy of a report from one of my close relatives that triggered the decision for me and had the handy notation right in the report to the attending physician, "Make sure that all of this patient's close relatives get a lifetime supply of MoviPrep because they'll use it," and to make sure that they ignored my appeal with full knowledge, I triple-checked the right address before mailing it in.

And in a few weeks, regular as clockwork, the post office delivered a new explanation-of-benefits charge with a payment to the GI. Woohoo! Except not so fast! There's this small matter of the anesthesiologist, who for some strange reason had his own accounting department. (I'm beginning to think that this is the result of midlife crises for doctors. "What'd you get, a Porsche?" "No, an accounting department." "With racing trim?")

So I thought a bit and asked some friends: what is the rationale for an insurance company paying for a surgical procedure but not for the anesthesiology? That's like listening to Sean Hannity without earplugs or watching the Miami Heat last year with any knowledge of how one should play the game called "basketball." I called up the insurer (yet once more) and after a bunch of "get them to change the diagnosis code" calls and a few detours, the customer service rep put me on hold for, oh, 40 hours. Okay, about 40 minutes instead. And said that he'd fixed it. I obtained some critical details and then called up the anesthesiologist. I talked with the accounts receivable staff, commiserated, and then passed along every bit of information I could so she could file the second appeal (which she volunteered to do). And now, finally, everything is paid.

... but for a few salient facts, such as the time I spent resolving this, the time two doctors' offices spent, and the fact that I was able to appeal successfully because I know how to work a bureaucracy. And in a just world, you should not have to have a graduate degree and several books that touch on bureaucracies to have it all work out in the end.

Coda (Italian for "tail"): I would have published this entry yesterday except for a family emergency. Two points about that: 1) I am therefore still justified in classifying this as an "out of left field Friday" entry; and 2) a family emergency will often involve much less trouble than getting insurance to pay for a medically-justified procedure.

Finally, please get your own tail to a colonoscopy if you're over 50 and haven't had one yet, or if you have the family medical history to justify one earlier. Colon cancer is preventable, but only if you're willing to get your insides checked out.

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Posted in Out of Left Field Friday on September 5, 2009 7:06 AM |