You Can’t Win at the Insurance Game

I 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. Wrong – denied. 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.

Advertisement