My health care battle continues with Anthem

It's so ironic that on the same day as President Obama's speech to the nation about health care reform, I was on the phone YET AGAIN with Anthem Blue Cross concerning the overage charges associated with my June 9 emergency appendectomy in NYC. I filed a grievance with Anthem in early July (see old post here) and I WON (see my older Aug 9 post here for more info). The charges that were a result of overages since the hospital I went to in NYC for this emergency surgery chose a surgeon who was out of network. Since I had no options to choose an in-network physician for this emergency surgery, I knew I would come out victorious.  As it turned out, Anthem said the surgeon was in-network after all (although it's still a mystery to me how). I received a letter stating that the overages would be written off.  I was both thrilled and relieved this happened. I really didn't feel like spending an additional $1200 on top of the $250 hospital admittance co-pay.

Unfortunately Anthem has not written off those charges yet. The first time I called they told me that it would take 14 days for the credits to appear from the award letter date. I would then receive a revised explanation of benefits.  The award letter was dated July 27, so you would think it would be taken care of by now. Surprise, surprise, it hasn't yet.  I called again on Aug 25 to check in about the credit/write-off, and was told it would take another 2 weeks. So I called yet again yesterday. I was told that it was held up in processing and that they would submit it again since the first time they submitted it didn't go through. So I have to wait another 2-3 weeks to see if it gets credited properly. And I will call them yet again. I will torment them until this gets resolved.

Why do I have to oversee Anthem's claims dept? Why do I have to constantly monitor their actions to see if they are performed correctly? Am I employed at Anthem as a quality assurance supervisor? I certainly am not. Do they even have such people who work there? It sure doesn't seem like it. Is it the people that work there who are the problem or is it the system? 

Here's my theory.  This is a game the insurance companies play with insureds in order to optimize profit margins. They purposely stall credits, payments and such until the insured gives up out of sheer frustration. They don't count on people calling in to try to correct THEIR mistakes like I do. I am the exception to the rule. I learned this behavior from my mother, who has had her share of insurance company battles over the years dealing with my late father's heart operations and other issues. I am holding Anthem accountable and have a letter stating that they would be writing those charges off. Those are the facts, plain and simple.

Unlike the 46.3 millions of Americans without health insurance, I am one of the lucky ones who actually does have coverage, yet I struggle for fairness. Actually my plan is quite nice aside from this particular situation. I can choose any doctor to see who is in the network and it costs only $20 each time. If I see a specialist like I did for my calf injury, it's only $25 per visit. Also, I have been going to physical therapy for the last 4 weeks at $20 a session. Not bad.

Why can't there be a plan that properly covers people if they have to use medical services not in their home city or state? Why does it have to be such a struggle to obtain affordable coverage in these types of situations? Isn't that the whole point of having insurance in the first place? Americans want peace of mind from insurance. Now, when I travel I don't have that secure feeling. I worry about the next freak incident that is going to cause me hours on the phone with Anthem, trying to correct their mistakes.

Grievance Victory!

I knew the day had come. On my way to pick up the mail at my PO box I was extremely nervous to receive a letter from Anthem Blue Cross. It had been 30 days since I filed a grievance with Anthem concerning my emergency larparscopic appendectomy I had in NYC on June 9. Apparently the surgeon they used for the surgery was "out of network" so I would have to pay for anything they deemed above "Usual, reasonable and customary". So I was slapped with an overage of $1200 and filed the grievance since it was so unfair. See my post here to read the entire background.

The letter I received on Friday stated, "Upon review of the above-mentioned claims we have found that services have been processed according to your in-network benefits. The provider of service, Dr. *****, is a participating provider. The claims were originally processed under your HMO group number and this provider does not participate in the HMO network. We have adjusted the claims to be processed under your PPO plan group number. We apologize for any inconvenience this may have caused."

This entire ordeal is so strange since I was told directly from an Anthem service rep that the surgeon was NOT in the PPO network and I would have to pay the overages. That is why I filed the grievance in the first place. Why was I told one thing and now this letter is reflecting the opposite? I guess I am not going to question this further. Frankly, I would like to keep the $1200 I would have had to pay. It's just a clear example of a severely screwed up health care system.

The ENTIRE TIME no one at Anthem Blue Cross could have simply looked up the surgeon's name in a fucking database and found out he was "IN NETWORK" according to my PPO plan??? This is the US health care system at its worst. Unproductive. Wasteful. Inefficient. Unsatisfactory. Note to President Obama, please fix this! I really hope a heath care bill can get passed in 2009. I already know that not everyone is going to be happy with this reform but this country needs something. There are too many people who have no insurance and then end up in the ER with a $28,000 bill and no way to pay it.