You Can’t Win at the Insurance Game

DeeDee newI am extraordinarily lucky: I have complete coverage health insurance. That means all therapy, lab tests, prescriptions, and other services – even chiropractic – are covered 100%. It sounds too good to be true, right?

It is.

The catch is that it’s a high deductible plan, and while my husband’s employer pays the bulk of the $11K deductible, we pay about $2K. No problem, I said, I’ve done the math and that’s cheaper than copays. Our portion of the deductible comes out of an FSA (flexible spending account), which is drawn pre-tax out of my husband’s paycheck throughout the year, so we’re not suddenly scrambling to make ends meet while we pay our portion of the deductible.

So far, so good, right? Well, the problem is that the deductible scheme is managed by a third party benefits management company. At the point when our part of the deductible has been paid up, we have to submit “shared responsibility” paperwork to the middle men, demonstrating that we’ve paid $2K+ and now it’s time for them to start paying again.

That paperwork literally takes hours; we can’t afford to pay our (my) expenses out of pocket while waiting for the monthly EOB (explanation of benefits) statement, so I spend a lot of time collecting the various documents and preparing them to submit. They usually process it in 7-10 days and turn my health debit card back on (without telling me that it’s now working again, of course), but as anyone with an expensive prescription knows, that’s enough of a delay to break the bank and/or brain.

Supposedly you get reimbursed for the portion you’ve paid over the cap when you file those forms. However, because of the way they pay the reimbursement out, it would take an auditor to figure out whether everything was properly reimbursed. From the last round, it looked like the reimbursement came in about $400 short.

Still not sounding too bad? Well, the middle men also require me to submit documentation of my expenses – uploading scans or photos of bills. They said it would be occasional, but somewhere along the line, they started requiring almost every single provider bill. To me, that smells funny; they definitely didn’t require this much paperwork last year. The HR person claims that the middle men need documentation of everything, but they’re inconsistent about what bills require the documentation. It’s either bait-and-switch or we’re being targeted for using our benefits.

And then there are the bills that you receive after the “run out” deadline; after March 31, they will no longer pay expenses from the prior year. But sometimes providers don’t bill in a timely fashion; for example, I got a bill in May 2013 for lab work from August 2012. So I called customer service to find out the proper procedure: I filled in a claim form, which would be denied out of hand, so I also filed the appeal form for the inevitable denial. This is a straightforward appeal, and the exact same situation as the form itself gives as an example: “my plan benefits ran out but I didn’t get the bill until this date so I couldn’t submit it by the deadline.” Apparently that’s supposed to just get approved. Wrongdenied. So now I’ve submitted a second appeal, and if that gets denied, I think 1) my head will explode, 2) I will have a fit of hysteria, and/or 3) I will take a lethal weapon to their offices and persuade them to give me my piddling $125 (which is not even their money, it’s my husband’s company’s money.)

Worse yet, earlier this year I settled a doctor’s bill out of pocket for $375 because after hours on the phone with the doctor’s office and the middle men, it became clear that a fundamental mismatch in their billing systems would require an appeal process. It was also obvious that there was no way that the appeal would be approved. I had a complete meltdown over it, and then just paid the doctor with money I couldn’t afford because I couldn’t handle any more stress. I just don’t have the energy to fight the system day in and day out.

Pretty soon we’ll have exhausted our entire $11K deductible, and then our insurance company picks up the bill, 100%, and I shouldn’t have to deal with the middle men anymore. But soon isn’t soon enough. I’ve had it up to here with the extra work. I’m tired of flipping out first thing in the morning when I find yet another request for documentation in my email. I’m furious with having to waste my work time on accounting tasks that no insurer has ever required of me before. I’m angry at being denied reimbursement on legitimate charges through no fault of my own.

While I love having good health coverage, this “shared responsibility” plan is ultimately detrimental to my health! It has caused so much stress and so many tears that it’s absurd. Any time I have to communicate about it or deal with yet another complication, I have to take a sedative to calm down enough to function. That’s just wrong.

But this also concerns me because I see it as discriminatory. A healthy person like Mr. Chickadee needs very little to remain healthy–he routinely goes 5+ years between “annual” exams–and will therefore be burdened with very little additional paperwork. The system is set up so that the more benefits you use, the more work you’ll have to put in. It sounds fair until you realize that this system basically penalizes people with chronic health conditions by burdening them with far more paperwork (and stress) than a healthy person would ever encounter.

A genetic freak like me, who has several health issues and needs very expensive brand-name drugs and quarterly transvaginal sonography and monthly medication management and two kinds of therapy and the occasional visit to an extremely expensive specialist, has to manage her health – already a part-time job in itself – and then put in a bunch more work to manage the health care. Part of the idea behind this “shared responsibility” scam scheme is to incentivize frugal use of health benefits, which is not an option for someone like me. Instead, I feel like I’m just being punished for having lost the genetic lotto while retaining the nerve to use the benefits to which we’re entitled.

Today, I snapped. I transferred all the account info to Mr. Chickadee and told him it’s his turn to deal with this stuff, since he has lots of free time at work and I haven’t a moment to spare. I don’t know why I didn’t do that sooner – he never offered, but I never asked. It just never occurred to me to ask for help. Having pushed the paperwork off my plate, I suddenly feel a lot better. I’ll do my share of the work by focusing on managing my health, and my darling husband will help me succeed in that by managing the health care. We make a great team.

© DeeDee and A Canvas Of The Minds 2013. Unauthorized use and/or duplication of this material without express and written permission from this blog’s author and/or owner is strictly prohibited. Excerpts and links may be used, provided that full and clear credit is given to DeeDee and A Canvas Of The Minds with appropriate and specific direction to the original content.


18 thoughts on “You Can’t Win at the Insurance Game

  1. The insurance industry in this country is broken beyond repair IMO. Instead of being there in case of a rainy day, their entire purpose seems to be “make it as difficult as possible” and literally weighing you down with so much stress and aggravation that you give up the fight. Frankly I think the insurance industry is as bad for my health as anything truly deadly. I have “decent” health insurance through my husband’s employment as well (bringing me to another rant about healthcare being tied to employment) but they seriously make things so difficult, I wonder if it is even worth it.

    • It’s also pretty amazing how many limits there are on even “decent” insurance – most universities have “good” insurance but you’re still in a prescription co-pay paradigm that seriously punishes anyone who has to take brand drugs.

  2. Insurance in the United States is a total bait & switch scam. And, insurance companies definitely target heavy users, there is no doubt about that. They try to make it as hard as possible to utilize benefits that are supposed to make things easier. This is the healthcare “sytem” this country has wrought — it is made only for people without chronic illnesses — and it won’t get any better anytime soon.

    • I think that’s just it – this system is made for people without chronic illnesses, but it’s also made to convince you to avoid preventive care, so more people end up with chronic problems because they weren’t provided services that could have helped them avoid developing a more serious condition. Lovely, isn’t it?

  3. Our healthcare system is very very broken. Those in power don’t want it to be fixed and neither to do the fat rat bastard insurance companies that are making money hand over fist by denying care. Sorry you had to endure this.

    • Thanks – there’s definitely a mismatch between supply and demand on so many levels when it comes to health care.

  4. thats awful! and youre right, definitely discriminatory against those who actually use their benefits. they dont actually want you to use them, just to pay your premiums/deductibles. good luck with that, hang in there.

    • Oh, this scheme is definitely and admittedly designed to convince you to use less benefits. That’s just not an option for everyone, which I think makes the whole notion fundamentally flawed.

    • Yep. Pretty soon we shouldn’t have to deal with much of anything anymore, but it’s a nightmare getting that far.

  5. Ugh, red tape is disgusting. Vogons should all disappear into a black hole, never to be seen again.

    I am very lucky here in Canada. While my prescription is not covered, therapy and lab tests (including hight tech ones like MRIs) are and I don’t have to do any kind of paperwork. All I have to do is present my health card and the government takes care of the rest.

    I can’t imagine the impact of red tape-induced stress in your health. Must be truly awful. HUG

    • The paperwork is what kills me at this point. I’m very careful about keeping receipts and everything, but it’s still a lot of idiotic work.

      I’d have major problems if prescriptions weren’t covered. Mine are just too expensive to buy outright, or to pay a percentage of the cost like most US insurance requires. I’d have to make $10K more a year to afford my medicines.

  6. Deedee,
    I clicked “like” purely because of your last few sentences about you and Mr Chickadee working through this as a team. I think those “middle men” need shooting. This system they have in place sounds like it’s actually designed to push people over the edge that they’re barely clinging to with their finger-tips. I cannot understand why healthcare has to be so difficult, whatever country you’re in.
    Faith x

    • Systems like this are designed by healthy people, for healthy people. Healthy people seem to think that those with health problems deserve it somehow, as if it’s our own fault. That may be true in some cases – especially when preventive care wasn’t available – but some of us are just born with problems that we can’t do anything to fix, and that’s where it becomes really problematic.

  7. It is interesting you wrote this, as I was going to write a post about Insurance cover also. Things are quite different here in Australia – and my concern is more with my Life Insurance and Income Protection Insurance. They include clauses that exclude any payment related to depression or anxiety (due to my medical history) – what exactly those illnesses are is not very clear to me and seems like an easy get out for the Insurance Company in the event I need to make a claim.
    Maybe I will write a post in the coming weeks.

    BTW. Glad to hear you reached a good conclusion in the end – you guys do make a great team!

    • Life insurance and long-term disability insurance are often just as bad in terms of discriminating against people with mental illness. It’s usually tied to employment in the US, so if that’s how you get that coverage, they’re not likely to deny it out of hand because it’s negotiated at group rates through the employer and they’re not looking at every individual. Most of the time. As for what it actually covers, that’s a different issue altogether, and it completely depends on the employers’ arrangements. Even if you get long-term disability insurance, that still runs out eventually, and then you’re at the mercy of social services to decide you’re sick enough for government-paid disability support. I’m guessing that perhaps the Income Protection insurance is like either long-term disability insurance or unemployment benefits in the US?

      We do have FMLA which gives us a right for unpaid leave up to 4 weeks per year (I think) for medical and family reasons (without losing your job, anyway), but actual “sick leave” is incredibly variable, and depends on the employer. I use my entire monthly quota almost every month just for doctors’ appointments, and that’s under-reporting how much time I take out of my work week for health care.

      Anyway, you should definitely write that post! I’m curious how the Australian system works and you’re bringing up a different set of issues as to what is covered and what is not.

  8. I’m so glad you wrote about this topic, in your own inimitable way. I just wrote a piece about healthcare in America for a blog for which I freelance–and it came down to this: unless you have the Cadillacs of insurance, do NOT GET SICK. That’s the best advice I can give.
    Meanwhile, I’m amused (or really I WOULD be amused if I weren’t so upset). I had ECT, and in the middle my employer switched insurance companies. So far so good, right?
    Turns out the second company is trying to deny me coverage because (drum roll, please). . .I had a pre-existing condition AND was not pre-approved. Perhaps I should have taken off the electrodes, asked which doctor they approved of, and had a second pre-op, since that’s really the cost-effective way to go about it. About the pre-existing-not much I can do.
    I thought that would give you a chuckle. And the fact that, unlike your insurance which sounds amazing, my insurance has never HEARD of the genotyping, and, as such, has no intention of covering it one iota. I guess actually looking into it would really be too much to ask, right?
    Anyway, keep the topics coming–I so enjoy your take on things.

    • Oh, how perverse! I had a similar situation when my husband’s employer switched dental insurance providers. I had gotten halfway through a dental implant procedure and the new insurer wouldn’t pay anything, not even the usual 50%, for my crown because the work was started under the old insurance and therefore didn’t qualify. Even though I had no lapse in coverage. I never got warning enough to find out that this would be the case, much less seek pre-approval or some such nonsense. We have since declined dental insurance because it’s completely useless and actually costs more than paying our dentist’s fees out of pocket.

      As far as I know, genotyping is considered a lab service just like any other. In fact, the FDA recommends it for some prescriptions (like ye olde fluoxetine) and it’s also recommended for some health conditions and procedures like certain organ transplants – but it’s not required for anything yet, although it should be. You’d be able to have it done with Medicare so long as a doctor prescribes it, so it’s ridiculous that your insurer wouldn’t pay for it. If your lab work is generally fully covered, then this should be too. I have a brand of Blue Cross Blue Shield so if you’re under any BCBS provider and they claim that they don’t pay for this service, that’s BS.

      The insane part about your insurer refusing to pay for max $4K in testing (mine only actually paid about $2K for it with their crazy, incomprehensible price negotiations) is that they’ll end up paying far more in the long run on treatments that don’t work, and additional health care services to address resulting problems. For me, between that testing and the $99 for 23andme (if you’re patient and studious, you can extract a LOT from that raw data) I’m also able to avoid creating new health problems for myself from taking OTC painkillers, codeine, or warfarin – all of which would cost the insurance company a lot more money to deal with retroactively.

      On the plus side, having full coverage means that I don’t hesitate to use services I need or get the drugs that work right, which in the long run will improve my health and maybe even reduce the use of some benefits. I worry more about the continually degrading quality of prescription coverage than anything else, because when I next switch employers I probably won’t have this level of coverage, and that’s where I could get hit in the face with a situation where I need a substantial pay raise just to cover the gap for co-pays on brand-name drugs.

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