This post is about insurance. Not about the having or not having, the benefits, the upsides and the downsides. It’s about coping with a maze of trap doors, sliding mirrors and black holes that magically appear when trying to figure out how insurance stuff works. I will try to keep this under 30,000 words. Wish me luck.
Insurance plays by its own rules
The upside is…. We HAVE health insurance, and we don’t have to pay ObamaScare tax penalties (yet). We have an insurance company that answers its phones, with helpful people who are trying their best to be helpful, under conditions that would try the patience of a saint.
The downside is… Insurance companies don’t speak or write non-insurance English (yet). They speak in tongues, and write in a symbolic ‘language’ as intelligible as Klingon to a non-Trekkie (non-Trekker if you’re closer to Gen X than Baby Boomer).
Insurance companies aren’t allowed to tell you all the rules at once
Today I learned that, since we live in California, a medical claim from a medical care provider IN California is not allowed to go straight to our insurance company. This differs from the way claims have been handled for the last 24 years that I’ve been a member, or at least it differs as far as I am aware.
Who knows. It could have been this way all along and we’ve been having a 24-year streak of astonishing good luck not to have had medical bills that rival the United States of America’s defense budget.
California-based medical care provider claims must go to another insurance company, which will then send the claims on to our insurance company. Maybe. Or not.
Also, just to keep things nice and surprising, any claim from a provider in our network is subject to being denied until and unless it is processed properly, and apparently the majority of California-based claims that have been processed at all may have been processed pretty much by accident.
My case worker stated this in such a way that she was assuming that I understood what she was saying.
Yeah. I did not.
It gets better. There’s homework.
Also I should read our insurance plan benefits brochure, because all is revealed therewith. It is on the website.
I have tried to read it. Several times. Even before I got cancer.
I don’t speak Insurance, and should have taken a trained insurance-specializing mountain guide with me before attempting to climb this Mt Everest of a comprehensive plan benefits brochure.
First, they lie. They call it a ‘brochure’ as breezily as one might call War and Peace a bit of a long novel. This ‘brochure’ has 118 pages in it.
To reimburse [Ins. Co] on a first priority basis (i.e., before any other party) in full, up to the amount of benefits paid, out of any settlements, judgments, or other recoveries that you or your representative obtain, from any source and no matter how characterized, designated, or apportioned (for example, as “pain and suffering”). [Ins. Co] enforces this right of reimbursement by asserting a lien against any and all recoveries obtained, including first party Medpay, Personal Injury Protection, No-Fault coverage, Third-Party, and Uninsured and Underinsured coverage. [Ins. Co] lien consists of the total benefits paid to diagnose or treat the illness or injury. [Ins. Co] lien applies first, regardless of the “make whole” and “common fund” doctrines. No reduction of [Ins. Co] lien can occur without our written consent, including reduction for attorney’s fees.
Decipher that on chemo fog brain.
Show your work for extra credit.
I’ve now resigned myself to hand-copying the entire brochure in various ink colors onto college-ruled notebook paper, one paragraph at a time. If I’m lucky, ancient history will repeat itself, and I will absorb the material whether I want to or not, by writing it out long-hand, whether I understand it or not.
Insurance companies don’t play by the same rules
– nor do they play by the same rules all the time. This little tidbit came by way of my cancer care manager (at least that’s what I think she is), who informed me that she doesn’t work with the incoming claims that are not directly to do with my cancer. Except for, perhaps this one and that one, and a few over here which she’s been able to resolve, but not really because that won’t work anymore. Unless they do.
ME: “So, what do I have to do to get these diagnostic and lab services claims resolved since you can only work with claims to do directly with the cancer?” (That’s me parroting what she said a few minutes before about what she’s allowed to work on as a cancer care case manager.)
CCM CM: “Oh, just let me know which ones you need help with.”
Well, ok, but didn’t she just tell me that she can’t deal with claims that are not directly to do with the cancer? Yes. Exactly.
>CLICK< (I’m not sure which of us gave up first. It could have been me.)
Later that day, same company, different case worker, different bill:
CW: “You should be calling us each time you get a bill or a claim that generates a bill you haven’t gotten yet, so we can see what needs to be done.” Wha…?
ME: “The claims still come from you, right?”
CW: “Yes, we send you the claims.”
ME: “So you would know before I do that there is a claim coming to me that will generate a bill, since Member Responsibility will be greater than zero? And, perhaps, call me? Since we need to speak about every claim that generates a bill” (You go, girl! PROVE that negative.)
Just to shut me up, she throws a butterscotch twist into the mix.
CW: “We can’t call you, though.”
ME: “You called me this morning at 6:20 AM.”
CW: “That wasn’t me.”
ME: “I didn’t say it was. I was using the Royal ‘You’, as in ‘all y’all who work at [Ins. Co.]’ The one who called me this morning was [my cancer care case worker] who works at [Ins. Co.] just like you do.”
CW: “Well, maybe she was returning your call?”
Score: Case Worker: 1 ; Confused Client (me): 0.
I decide not to bring up the fact that my cancer care case worker calls me out of the blue on average three times a week, usually long before I wake up. I really don’t mind early morning calls when the results will yield massive amounts of savings on my medical bills.
ME: “Ok, but what about this claim that got denied but then paid but then billed to me as if they were out of network?”
CW: “Oh, no, I am flagging that one to go down for review.”
Me: “OH thank you! How will I know what to pay and when?”
CW: “We’ll send you a letter.”
ME: “Ok, thanks!”
CW: “Unless it turns out that they really are out of network, in which case we will send you a different letter.
“Unless they are in network but were billed as out of network because they didn’t send the claim over to [Ins. Co #1] who will send it to us for processing, which is how all California claims need to be handled.
“We’ll send them a letter, too.”
By now, I am as lost as soup at a colander convention.
“But why were all those claims that were sent directly to you instead of through [Ins. Co. #1] processed properly as in-network then?”
“Sometimes we get lucky.”