Thanks for the advise....NOT!

The surprising mammogram news came this week. Suddenly after years of hearing that woman 40 and above should get a yearly mammogram, we hear that they are not needed until 50?

Hmm…telling adult woman NOT to do preventative screenings? What is wrong with this picture?

After the news hit, there has been quite an uproar. Woman everywhere are say, "This doesn't add up!"

Those screenings through your 40s can be baseline information for anything that pops up in your 50s. Mammograms are still one of the best early detection tool for breast cancer.

And just today I read from ABC news, that women have been getting too many pap smears too? Why?

Because they are just so darn fun? I don’t think you need to be a woman to detect my sarcasm on this subject. Pelvic exams are one of the most invasion, annoying and embarrassing procedure to get done. Yet, woman who take their preventative health seriously get them done, year after year.

So why the big change? Good question but I doubt if we will get a cogent answer from on high very soon.

Call me a flaming skeptic but does this have anything to do with the contentious health care reform debate bubbling forth all over the country?

Is this a way for the insurance companies to not cover preventative screenings? Yes, to me at least, it looks like it is.

So, to be clear - I am not a doctor and I am also not a lobbyist for the health care industry. I am a 45 year old woman who has been having mammograms on a yearly basis since I turned 40. And, I will keep on doing it even if those extortionist insurance “providers” won’t cover it!

Call me a skeptic but I don't think I trust my long -term health (or anyone else's for that matter) to the obvious monetary dictates of the insurance industry.

What do you think?

Autistic parent sues California Department of Managed Health Care

Could this be a sea change?

It seems more and more folks are stepping up and calling foul on not covering needed therapies for autistic kids.

Too loud to ignore, they won't be able to do it anymore.

From the Autismeducationsite.com:

The mother of an autistic child joined Consumer Watchdog and its attorneys today to announce a lawsuit against the California Department of Managed Health Care (”DMHC”), the Schwarzenegger Administration agency responsible for regulating many of California’s health insurers. The suit alleges that the DMHC has wrongfully allowed insurance companies to refuse to pay for autism treatments, resulting in the denial of critically needed, medically necessary treatment for autistic children.

The suit, filed by Consumer Watchdog and Strumwasser & Woocher LLP, alleges that the DMHC, and its Director Cindy Ehnes, recently changed the state agency’s policy to permit insurers to deny coverage for Applied Behavioral Analysis (”ABA”), an essential treatment for autism, in plain violation of the California Mental Health Parity Act. That law requires health insurers to cover and pay for all medically necessary treatments for autism, including ABA. If successful, the suit would require the DMHC to bar insurers from refusing to cover medically necessary ABA treatments. The suit also seeks to compel the DMHC to turn over records that would expose the full extent of the DMHC’s violations of the California Mental Health Parity Act and the Knox-Keene Act.

“Californians, including those stricken by autism, and their parents and caregivers, expect regulators to enforce the law, not to side with insurance companies seeking to boost their profits by denying patients the care they need,” said Harvey Rosenfield, founder of the non-profit advocacy group Consumer Watchdog and author of the landmark insurance reform initiative Proposition 103. “Governor Schwarzenegger, a longtime and vocal supporter of the Special Olympics and developmentally disabled children, will now have to explain in court why his administration is allowing health insurers to evade state mental health laws and shift health care costs to already beleaguered taxpayers.”

Blue Cross Settles $1 million autism suit

Over 100 families to recover autism therapy fees after Blue Cross refused claims.

From Justicenewsflash.com:

Detroit, MI(JusticeNewsFlash.com)–Blue Cross Blue Shield of Michigan settled with about 100 plaintiff’s for $1 million in Detroit’s U.S. District Court regarding unpaid autism therapy. According to the Attorney General, families paid $10,000 for behavioral therapy treatments at Beaumont Hospital for their young autistic children. The parents and families of the autistic kids paid $10,000 for the specialized, needed therapy. The settlement will help families who paid for the costly treatment at Beaumont Hospital, Royal Oak, since 2003.

Blue Cross Blue Shield of Michigan will now offer the behavioral treatment for young autistic children who are covered under their parent’s group mental health policies provided by employers. The insurance coverage will be available to children between the ages of 2 and 5 years old for up to 12 weeks of treatment. This is only applicable if the parent’s employer offers mental health coverage through Blue Cross.

JusticeNewsFlash.com news for Michigan insurance litigation lawyers.

Parasite

I know. And, it's really getting painful!

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.