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.

Filing Grievances with Insurance

I went into my Anthem Blue Cross account online today to check on the claims related to my emergency appendectomy that I had on June 9 in New York. They have already screwed up once since they posted all the claims to my OLD insurance account that I had at my former employer. I also had Anthem and my new member # is almost the same except for the prefix sequence. When I was in NYC I told the hospital to use my new insurance. I even limped my way went down to the billing dept after I was discharged to MAKE SURE they had all the correct info. Still, it was charged to my old insurance. Great job! I called today and Anthem is going to post the charges to my new insurance acct that went into effect on June 1. So at least that issue will be taken care of.

Unfortunately there was another serious billing issue I discovered. I was reviewing the claims online because there is a separate claim for each doctor. For example, the anesthesiologist charges a separate fee. The radiologist charges a separate fee, etc, etc. There were 3 separate charges for the surgeon who performed my appendectomy. Anthem will not pay the entire claim because he was an "out of network" doctor. Although it has not been billed yet and it says "pending" on the online claim, my possible portion of the bill will be $1666!

How would I have known the doctor was out of network? Oh, I guess I forgot to ask while drugged up laying naked on the operating table, "Before you slice open my abdomen, is the surgeon in my network?" The hospital did what they needed to go to get my surgery completed and they had to call in a specialist. I understand that completely. This was not a planned operation and I HAD NO CHOICE IN THE MATTER. That's what an ER is all about - the unexpected. I didn't PLAN to have my appendix almost burst while in NYC. Now, this argument hopefully, will save me $1666 in charges.

The Anthem rep, who was amazingly helpful, told me that he hears these cases all the time. HE told me he would file a grievance for me. I will know in 30 days what the judgment will be. He says they have an entire dept at Anthem dedicated to researching grievances and negotiating with the various doctors who charge the exorbitant fees.

What I don't understand is why I may be responsible for charges that could have been prevented. It's not fair and I actually have insurance! What is wrong with this picture? Should I have refused the operation and risked my life? What about all the people who don't even have insurance? Here I am, possibly having to pay $1666 for an operation that, according to my insurance, should have only cost $250. That's right, according to my benefit coverage, if admitted to a hospital I only have to pay a $250 co-pay and all physician and surgical services are covered at 100%. That is for in-network though. Could the hospital used one of their own doctors to do this surgery? I have no idea. Again, I had no control over the situation and I wasn't making the decisions. The decisions were being made FOR ME. I was out of the loop and shouldn't pay the price. I was traveling on business and had no idea this was going to happen.

It seems like I should have a great case to escape the charges. I hope I do. Although I have no idea what the Grievance Dept at Anthem does exactly, the rep told me the rep told me they deal with these situations all the time with out of network doctors charging INSANELY high fees. Oh I almost forgot, one of his fees for "ER services" cost $1125. I only remember seeing him one time just before I went up to the operating room. All he said was "Hi. I'll be performing your appendectomy tonight." That was it. What exactly cost $1125? He never touched me in the ER. He was in street clothes and looked like he just got there. Also, the day after the surgery he came to see me for about 3 min and looked at the bandages. That cost was $595 and my portion is $350! Whatever. I really hope Obama can get universal health care passed so everything is regulated. This is out of control.

Less Pain and Faster

Today's run was a lot better than yesterday although my heart rate was higher. I ran 4.8 miles in 32:44 for a 6:47 pace. My heart rate reached 179 (96% of MAX!!) but my average overall was 159 (85% of max). I did not feel any abdominal pain during the run. I just had a lot of general pain from a lactic acid build up. Before yesterday I had not run for 15 days so I will be sore this week as I get back into it.

The good news is that the pain I was feeling in my right Achilles area has not come back and my hamstring seems to be fine. I had this Achilles issue for about a month and a half before I had my appendectomy 2 weeks ago. After suffering the hamstring injury while playing tennis in Dec 2007 and going to physical therapy twice in the past year, I believe I have finally kicked this injury. What I have learned: hamstrings take forever to heal, sometimes well over a year. They are stubborn muscles that need time.