Monday, October 20, 2008

Blood sucking parasites or dealing with the insurance company

Being a compassionate, bleeding heart liberal, I automatically try to put the shoe on the other foot in most situations. Dealing with the insurance company was no different. During my extensive dealings, all I could think was; how do these folks do this for a living? It's just a job, I know; I was just one more distraught, pleading voice on the phone. Same stuff, different day. But, many of these folks are parents too. Some are even battling for their own kids sake just like me. After a while, with some of them, I even detected a whiff of understanding and, dare I say, shame when they continued to give me the run around.

Since both Jake and I are self employed, we purchase our insurance on the open market. So far we're lucky; we have been able to afford it. Because we are relatively young (44, & 49), our policy ONLY costs us about $750 a month. Lord help us if we had any pre-existing conditions or it would be much more or they would refuse to cover us at all.

We never really needed our insurance until Shea's speech issues came along. With private therapy, quite literally costing us a small fortune a year, I was going to do my darnedest to make sure the insurance company covered what they promised which, quite honestly, wasn't much. For those of you who don't know, insurance coverage is notoriously whispy when it comes to Neuro-therapies. My policy will cover $2000 a year total with a specialist "within their network" or $1000 a year total for a specialist "outside" their network. This is for a specialist who costs between $75 - $125 an hour. You do the math. Their coverage ends up being a small fraction of the real out of pocket costs. But, to even get that fair, you must capture the elusive pre-authorization. I have found it comparable to the search for the holy grail.

My attempts to get the pre-authorization for Shea's Speech Therapy were excruciating. I sent in 3 separate batches of records; background, evaluations, etc. I called and spoke with amazingly unwilling or uninformed customer service people who gave me different addresses and strange fax numbers. They said they never got any of my paperwork.

Bubble lady sent complete paperwork packets twice as well. They insisted they never got them or said we were not covered. I trotted around this track for about a year. At a certain point, I remember just hanging up on the minion that was trying to cheat me and just cried, totally spent. It seemed particularly cruel to prey on the most vulnerable patients in need and take advantage of the weakest, most stressed out parents.

So, what do you do if you are in this vicious cycle? Don't give up; that is exactly what they want you to do. They want you to keep on paying your premiums but to just give up trying to get them to honor the policy because it is literally too much work. Oh, and it is. I have never felt more fruitless and obsolete than when I was battling the insurance company.

Solution? Go over their heads to the State Insurance Commissioners office. Simple; call them on their fraud and bad dealings and go to the state regulator. Most states have websites that instruct you how to start a case. Document, document, document; write a heartfelt letter explaining your situation (be civil, professional and do not drag on too long), include all pertinent policy numbers, addresses and phone numbers of the insurance company, doctor's referrals and evaluations, a detailed timeline is helpful as well as appropriate verbiage from your policy that backs up your claim. MAKE COPIES OF EVERYTHING BEFORE YOU MAIL IT!

Once it's in the mail; relax, calm down, hug your kid, kiss you partner, twiddle your thumbs but don't hold your breath because after all this is the state government. They will respond eventually but you need to be patient.

I was assigned a case worker with an actual name and a phone number who I could call and talk to. He sent off very official, sternly worded correspondence to the insurance company and as if by magic the mountain began to move. Don't start celebrating yet because it took two more rounds with my case worker for them to actually issue a pre-authorization number, start accepting claims and reimbursing me. I was persistent. In fact, by that time, I was ferocious, I wasn't crying anymore, I was pissed. Being pissed helps a lot; crying and asking for help doesn't.

I like to think that I beat them at their game but I probably just got shuffled into a "pain in the ass" stack. Whatever; it felt good. But, the celebration is short lived and the saga isn't over; my policy will only cover this small fraction of Shea's therapy costs until he is 6. And, get this....I have to re-apply for the authorization each year until then, after which, of course, they won't help at all anymore.

You see, it doesn't really matter that he will need speech therapy until he is probably 10, 11 or longer, they have determined how long they will help my son.

That, my friends, is what a FOR PROFIT healthcare system buys you.

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