Op-ed column: Don’t bet on it

I recently received my forth rejection notice this year. It wasn’t for a car loan or a screenplay o

I recently received my forth rejection notice this year. It wasn’t for a car loan or a screenplay or a job application, it was for a health insurance claim.

These are not isolated incidents and I’m sure my story is not unlike many of yours. My company is Empire Blue, but I know, and will explain how I know, that this is a universal problem which we all suffer from. Let me briefly describe two personal examples.

I have a lifetime coinsurance of $6,250. This means that after I have paid that much in coinsurance I don’t have to pay coinsurance any longer.

Unfortunately, I met that amount some years ago and should be free and clear on coinsurance payments. I say unfortunately because one has to be pretty sick and require a lot of care to meet that limit. Some people never do, or they have a plan where they always will pay a small amount, or perhaps have a yearly limit rather than a lifetime limit and never reach it. Sort of a good news-bad news scenario; if you stay fairly healthy, you get to continue to pay your coinsurance. Although I’ve met my lifetime amount, my company continues to bill me for it. Which also means that they pay that much less to my doctors.

I call and go through the obligatory button pushing on the telephone and finally, after a pot of coffee and maybe lunch, a real person answers the phone.

I explain the situation, they put me on hold, and eventually come back and agree that I am correct. Oh, it’s not done on purpose, they assure me. It’s a computer glitch. One that apparently wasn’t fixed after my last four phone calls, but it will be corrected. I listen and complain. They are very nice and for sure the tech department will clear it up . . . until the next time.

Then I call my doctor and assure him that a check will be issued for the correct amount and please don’t put me in arrears while he’s waiting.

In another example, and I know this has happened to you, my insurance company refused to issue a prescription my doctor wrote because they don’t cover that particular medication. But they will cover a substitute. I tried the substitute and had an adverse reaction so the original medication was approved, but here’s the kicker: They would only approve a portion of it. In other words, they decided, not my doctor, that the side effects of my treatment that this medication is meant to alleviate only needed to be dealt with one third of the time. For me, that meant I got the right to sleep every third night.

Did some research

So how do I know that this is a universal and insidious problem? I’ve done a little research and have spoken to several people in billing at various doctor’s offices. They all say the same thing: This happens constantly and they spend an inordinate amount of time trying to get their money from the insurance companies. One person told me that it often takes several claims requests to get their money. She also said that many people just pay it themselves, either because they don’t realize they are already covered or they just don’t have the fortitude to fight what might be a small charge. Multiply $17 for coinsurance by 100,000 people and we’re talking about a lot of money. At $100 it’s a fortune.

This one I only heard second hand: A former employee of an insurance company stated that they were taught to “misplace” every third claim, forcing the doctor’s office to resubmit. The claims are eventually paid, but delayed payments are money in the bank.

Another example concerns the Medicare 80/20 plan where Medicare pays 80 percent and the secondary insurance picks up the 20 percent.

I was told that getting the 20 percent paid is often a nightmare of time-consuming, numerous phone calls while the doctor waits for his money. Another person told me that the “Blues” are the worst when paying their percentages while the HMOs are better. But in sharing the guilt, she mentioned that the HMOs are extremely difficult in getting prior approval for medication, in effect making decisions that should be made by the patients and their doctors.

Time for action

Something needs to be done. Perhaps Andrew Cuomo, who has done such a good job going after Wall Street, college loan deceptions and pharmacies promoting steroid abuse, can take on the health insurance industry. Perhaps a new approach to health care proposed by a new president will take our health care out of the hands of the insurance companies and put it into the hands of the doctors and the patients, where it belongs.

We have all seen the billboards reminding us that cheating on insurance claims costs all of us a lot of money and is fraud punishable in a court of law.

I submit that cheating by insurance companies also costs us a lot of money and also should be considered fraud. I don’t have a billboard but, unfortunately, many of you already know exactly what I’m talking about.

Anthony Frank lives in Schenectady and is a regular contributor to the Sunday Opinion section.

Categories: Opinion

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