Last Friday, I happened to pick up a copy of the Wall Street Journal somebody left on the train. There was an intriguing article on the front page — How U.S. Health System Can Fail Even the Insured.
It’s a long story but the story line is familiar. A Mrs. Barbara Calder has a rare genetic illness but she had to jump through one hoop after another to get her health insurance to cover the treatment she needed. I’m going to use this case as an example to show what to do if your health insurance says the treatment you need is not covered.
Here’s a timeline of the events. I’m marking my comments with [TFB].
July 2006 – Mrs. Calder suspected that she had Ehlers-Danlos Syndrome (EDS), a rare genetic illness which can be life threatening. She had health insurance through her husband’s employer. She called the insurance company about seeing a specialist. She was told she needed a referral from another doctor.
August 2006 – She received the referral to a specialist who charges $650 for a consultation. She verified that the specialist was in the insurance company’s network. Before she made an appointment, she called the insurance company again to confirm coverage but this time she was told the service wouldn’t be covered.
[TFB] You got the required referral and the doctor was in the network. So just go. Whether the service is covered or not can be sorted out later. The agents answering the phone are not the ones who process claims. They can be wrong. Whether a claim is covered or not depends on the ICD-9 codes the doctor writes on the claim form. Before you see the doctor, you don’t know what the codes will be. Even if the claim is initially denied, it can be appealed. Health is more important than money. Go get the diagnosis. Have the doctor bill the insurance. Worst case you will have to pay $650 yourself. It’s not astronomical.
September (?) 2006 – Unhappy about the insurance company telling her the consultation would not be covered, Mrs. Calder showed up unannounced at the office of the HR Director at her husband’s employer. She had an argument with him about her insurance coverage. Later, an executive at the employer’s corporate office in a different state was also involved.
[TFB] This was totally unnecessary. Managers at the employer don’t make health care coverage decisions.
October 2006 – Her husband was laid off. They suspected it had something to do with her condition but the company denied. They decided not to take COBRA because they couldn’t afford the $1,200 a month premium.
[TFB] Paying $650 for the consultation out of the pocket would be a lot cheaper than losing a job or paying for COBRA.
December 2006 – Her husband found another job but the new health insurance doesn’t start until 3 months later.
[TFB] Still waiting just to save that $650? Health is more important than money.
July 2007 – She finally saw the specialist and got a confirmed diagnosis. The specialist prescribed a drug but the insurance company refused to cover it. They wanted her to use some cheaper drugs first. The doctor also recommended a test to see if her condition was the type that could result in sudden death. She called the insurance company about the test. Because she didn’t know the exact term, the insurance company misunderstood and told her that the test would not be covered.
[TFB] If you need the drug, pay for the first prescription. Let your doctor tell the insurance company why you need it. Then your next prescription will be covered. Your first prescription will likely be reimbursed as well. If you need the test, go get the test. Fight it only *after* they deny the claim.
August 2007 – Her husband took another job for better pay. The new insurance had another 3-month waiting period. She became uninsured again because she thought COBRA was not worth it.
[TFB] If you keep skipping COBRA and have breaks in coverage like this, your pre-existing condition might be excluded by your next insurance company for one year. See Department of Labor’s FAQs on HIPAA.
November 2007 – Her health deteriorated. She still doesn’t know whether her illness is the more serious type because she never took the test. She’s worried about her children because the illness is hereditary. She wants to move to Belgium because Belgium has universal health care.
[TFB] How is it fair to have Belgian people pay for your health care? The U.S. health care system isn’t perfect. You just have to be willing to pay something out of your own pocket, most likely only for a short while. If the service is medically necessary, it will be covered eventually.
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