Dispatch from our dysfunctional Health Care system

Here in the US we enjoy the world's most expensive socialized health care system. The system provides insurance through private, for profit, insurance companies where most people get insurance through their employer. Depending on the employer you can choose between a limited set of health care options. All these have one thing in common: they are expensive, complicated, confusing, annoying, and ultimately result in loss of productivity of the American worker. And that's if you're lucky to be employed and have health insurance at all!

I call our system "socialized" because we get socialized health care. The patient experience is one where your doctor sees you for mere minutes before they need to run off and see another patient. There is no personal relationship with your doctor whatsoever, unless while you remain healthy. Our pets, who all see private doctors, in contrast, have wonderful personal relationships with their veterinarians. Going to the vet is a completely different experience, where everyone knows our names and the names of our dog and cats, and the vet takes ample time examining the critters and discussing treatment options with us.

So, here's a short story of dealing with our system. Is this a story of hardship, life and death, financial ruin? No, sorry. Fortunately the family is healthy and we're financially stable. This is a story of for-profit companies choosing the most rational path: denying health care, therefore maximizing profits. It's a story of ridiculous bureaucracy that results in overhead costs that aren't spent on the actual care. One of the compelling reasons to adopt a single payer system was to vastly simplify administrative procedures, therefore reducing much of the overhead. But we're not going there. Even after Obama's Health Care reform, the current system remains in place. In this story you see our dysfunctional system at work.

A Change of Employer

It all started in the end of 2008 when I switched to a new employer. The first thing you do when you join a new place is pick the Health Care option that's best for you. It's typically about which doctors you need to keep seeing. Our family has been going to the Palo Alto Medical Foundation (PAMF) for years, and all I had to do was pick the plan that had a deal with that clinic so that my current doctors would be "in network". There was only one choice: Guardian's PPO, subcontracted to Interplan.

The first time you go to see your doctor after such a change, you're asked to see the administration and give them the new insurance information. In my case the information was pretty simple. Guardian sent me a card containing my name, my employer, our group plan number and finally my own member ID. I passed on this information to PAMF and forgot about this altogether.

Claims and their Paper Trail

When you go see the doctor you are charged your co-payment, which can vary depending on your plan. Then the health care provider bills your insurance company for the services provided. If all goes well, the insurance company accepts the claim, pays the health care provider and you're done. You receive a statement from the insurance company explaining what happened (the instance, the amount billed, the amount covered) and you also receive a statement from the provider showing how much the insurance has paid and asking you to pay for the rest, if insurance did not cover you fully.

The statement from the health care provider is pretty simple. The one from the insurance company is incomprehensible. Typically it's accompanied by "codes" that indicate the reason something was not covered. The amount covered also can depend on various factors, including deductibles, and percentage of coverage based on an idealized expected total for the given procedure. The point of this is that it's non trivial to figure out what these statements are saying and it's non trivial to understand exactly what your health plan provided.

The Story

In 2009 I had to see a doctor for something. After a while I got a bill from the provider for about 100 dollars. I thought that was a bit strange, but assumed there was a small deductible in the plan and just paid it. That month I was probably too busy to look into it as I was doing the bills and the amount was not significant enough to trigger alarms.

This happened a couple of more times, and I paid again. Then I got a bill for $800. That one caught my attention. What was going on? Was the health care plan covering anything at all? Strangely, I noticed I had not received any statements from the insurance company. I assumed PAMF had misplaced the data I gave them on my first visit and called them to find out. Nope. They had all the data and we painstakingly double checked it all. It all matched. And yet, the insurance company claimed that my "identity cannot be verified". That is, they had my name, employer name, group plan and member id and somehow this was not enough to match the claim to my person. Mission accomplished. Claim denied, more profits this quarter.

Having spent a few hours dealing with this, and many more worrying about this mess, I talked to our HR department to make sure all my records where in place. They were. They suggested I call the insurance company to find out what the real problem was. Note that during this saga, these were hours in which I was not working. Instead my employer was paying me to debug whatever was going wrong in the health care chain. Let's move on.

Engaging the insurance company was the most time consuming. My insurance card is confusing because while Guardian is the insurer, the Interplan logo appears on the right hand top corner. I called on of the numbers on the card, which turned out to be Guardian. After explaining the situation in great detail to a couple of people, they told me to call the Interplan number.

I explained the situation to the person at Interplan and after a while we moved on to double checking my data. It all matched again. They saw no reason why the claims would be denied, so they asked me to tell PAMF to resubmit the claims. So, I called PAMF again and asked them to resubmit the claims to Interplan. They said they would.

A couple of months later PAMF contacted me to inform me that the claims were denied again. Once again we made sure all the data was in place and it was, and once again they told me to talk to my insurance company, who was still claiming they didn't know who I was. Interestingly as they seemed not to be able to ascribe the claims to me I never received a statement from them indicating that any claims had been denied. PAMF wanted me to call Interplan again.

I did that. At that point I had already spent possibly 10 hours dealing with this mess and we still didn't know what to do about it. After explaining my case in great detail yet one more time, the Interplan person I got this time wanted to know what the provider was entering into field 11.B and 11.C of "the form". I had no idea. I didn't even know what form they were referring to. They must have been talking about the Interplan form that PAMF uses to submit claims to Interplan. I've never seen any of these forms. No worries. They told me to call my provided and ask them to enter "Guardian" into box 11.B and the name of my employer into box 11.C, and that with that it should all work. Thanks for calling and good luck.

Back to PAMF. The person I talked to was extremely skeptical, but willing to make a note of this requirement into my record and have the claims resubmitted. We did that and waited a couple of more months.

At that point I finally saw evidence that the insurance company finally knew who I was. Claims were processed, I started receiving statements from them and, more importantly, I got a refund check from PAMF for the original doctor visits I had paid for by mistake. That was all last year.

This month I get a bill from PAMF for $500 for an individual doctor visit. While I think this is outrageous, what catches my eye is the fact that my insurance company has been contacted and this item is "not eligible for coverage". That's all the note says. So, I call PAMF and ask for more details. Once again: the insurance company does not know who I am. This time it's a claim for my daughter who's listed under my own account. Sigh.

Fortunately I've kept notes from the first time around and I quickly pass on this information to the billing department. It's been a year and maybe the relationship between providers and insurance companies has deteriorated because the person I talked to was veering on hostile when I told them what they needed to write in boxes 11.B and 11.C. She indicated the claim would be resubmitted and that's where we are at this juncture of the narrative.

Final Whining Points

We're still in line for a happy ending, but I'm still fed up enough to whine a bit more about all this. I've wasted hours of work time dealing with this crap and I have no confidence this is the last time I'll be dealing with this.

I have fond memories of my time as a student in Ontario, Canada. I was a member of Ontario's Health Insurance Plan (OHIP) and I knew that anything I needed would be covered. I never ever saw a medical bill and spent no time at all dealing with forms or worrying about health care at all.

Here in the US, on the other hand, even with a good job and expensive health insurance I'm not only constantly worrying about how much I'll have to unexpectedly have to pay but also have to deal with ridiculous denials like the one I just described. I really expected health care reform to include a Public Option. I was waiting for the day when it would become law and I would walk into my HR department and ask to transfer my whole family to the public, not for profit system. Not only do I not have that choice at all, but almost nothing changes for people with employer based health insurance. Clearly the system is broken, full in inefficiencies and yet it continues to be the system we deal with every day.


Popular Posts