Insurance Companies, Health Care Costs, and the Chronically ill

“The Need to Fight Back”

Medical insurance companies are out of control because they have too much control. The same can be said about pharmaceutical companies and other large health organizations like hospitals.

Getting coverage, keeping coverage, being able to afford coverage are huge headaches for us. We need them and they know it. These greedy companies have tremendous power and resources, leaving us at their mercy. They decline truly needed things that our specialists recommend for us.

A fellow MS Blogger, Dave Bexfield, recently won a claim against a large insurance company that wrongfully denied payment for his life-saving stem cell procedure. http://nyti.ms/1oUQ5ZK  His 4-year persistent battle that included the help of NY Times’ The Haggler finally ended with his victory.

A victory that hopefully will inspire many others to follow his lead and fight for their rights. More people need to do this; there is strength in numbers. We are the buyers of their products; our voices and actions against their wrongdoings as a group can impact their control. Especially if we get our victories publicized by all types of media and large organizations; like Dave’s involvement with the New York Times and his social media bombardment that followed.

Fighting for your rights from insurance companies is hard work, especially when you are ill. It requires a tremendous amount of energy, time, patience and often money; things that people—especially the chronically ill–don’t have much of. The frustration and stress that one endures with the phone calls alone can turn the sanest person insane–long hold waits, dropped calls, rerouted calls, not being able to talk to a person… Most people who take on the fight with these big guns eventually give up; these companies count on it.

Those of us who are truly sick and trying to have quality in our lives are getting doors slammed in our faces for things that could help provide more quality or relief. We pay big bucks for our insurance coverage with our limited incomes that suffer because of our disabilities/illnesses.

Give us the benefits we pay for or are entitled to! Blow the whistle when something is just wrong.

WHAT TO DO?

If your doctor recommends a drug, procedure, equipment, etc., make sure you get it.

An insurance company should NOT be the one who determines what’s best for your health—it should be your doctor and you!

Read your claim statements carefully to make sure they are accurate.

For example, I went into the ER last year for chronic constipation, and my $5,000 invoice was for a coffee enema. It also included a $258 charge for a pregnancy test. I was 58 years old! When I called the hospital about it, the response was “What do you care? Your insurance paid for it.” No–they didn’t pay for it, we end-users did. Well, I reported this incident to Medicare, who ultimately went back to the hospital. I blew the whistle.

Yeah, I had paperwork to fill out and follow-up to do, but it was worth it to screw back the hospital that screwed me.

Make sure you receive a detailed statement.

Some insurance companies don’t even issue detailed statements to patients. My 82-year old mother has an HMO with Cigna in Arizona and gets no paperwork for anything—not even a doctor’s visit. When she bragged about how easy it is not to deal with paperwork, I pointed out that failure of disclosure enables these companies to charge and cheat whom or whatever they want. Undercover fraud.

Take control over what is done, why it is done, etc.

When I was in the hospital last year for a bladder infection, there were so many specialists that came in my room and ordered tests. I demanded to know “why and what for.” These 5-minute doctor drop-ins cost an average of $400 each! The hospital charged $6 for each baclofen that I took, and wouldn’t allow me to bring in my own prescription from home, for the same med that cost 6 cents/pill! I take 5-6 of these per day.

There is something called the “Chargemaster” that hospitals use that is their grand price list for absolutely everything a hospital will charge you for. It is different from hospital to hospital and has no cost basis. Read this eye-opening, special-report article that was published by Time magazine if you are a Time subscriber: “Bitter Pill: Why Medical Bills Are Killing Us” by Steven Brill (March 4, 2013 issue) http://time.com/198/bitter-pill-why-medical-bills-are-killing-us/. It will knock your socks off.

Nursing homes and rehab centers are another area where there is much abuse with a patient’s medical needs and medical costs. My husband and I were caretakers for his grandmother, who spent the last ten years of her life in a nursing home. We took control quickly over all her medical needs when we discovered the who’s, what’s, frequencies and costs of the nursing home’s directives for Grandma’s care. We took over all decisions and we checked the costs incurred for everything, questioning inappropriate charges. And we sadly watched the other patients in the home who didn’t have someone overseeing their care get cheated and over medicated. Check out this AARP article: “Nursing Home Drug Outrage” http://bit.ly/1vxITrz  (Page 12)

 • While preventive medicine has its merits, common sense should prevail.

There are a lot of kickbacks between insurance companies, pharmas, and doctors. I’ll use my mother as an example again. Her doctor sets up a bone density test, pap smear, and mammogram every year. This is for an 82-year old woman who takes her required calcium/Vitamin D and doesn’t have a history breast or cervical cancer in the family??? Check out this article about kickbacks: “Payments to Doctors Revealed” http://bit.ly/1lAZ2pn.

Re: doctors, here is another interesting article: “Medicare Patients Can Now Do a Check-up on Doctors” http://bit.ly/1g9gtL9 . Consumer groups and news outlets have pressured Medicare to release the data for years. Now, Medicare officials said they hope the data will expose fraud, inform consumers and lead to improvements in care.

Everybody complains about the insurance companies and healthcare costs, but are their complaints followed by any actions to turn a wrong into a right? Ask questions and appeal over and over again until you win. Be a gnat on their back. Persistence pays off, like it did for Dave.

I had my own fights over the years with insurance companies over so many things for different types of equipment (like a stair glide) or a procedure (like trigger-point massage). They wouldn’t pay for trigger-point massage that would provide pain relief from spasticity, but they would cover painkillers—additive narcotics that alter cognitive functions and cause constipation. No thank you.

Even though I lost some disputes, I won some too. Here are my favorites:

Thirteen years ago, I sought reimbursement for a $2,400 pool lift for my swimming pool, which was denied. I had been doing aquatic therapy three times a week for twenty years—paying out of my own pocket–and pointed out that an hour of physical therapy that was of lesser benefit to me costs $200/hour. So twelve PT sessions would equal the cost of the lift, and I would have year–round therapy conveniently at my home for years to come. After numerous letters and three appeals, I was scheduled for a meeting with their Board. At the meeting, I had aquatic therapy documentation and representation from my doctor, the MS Society, and family members.

It was finally approved with the caveat that this was clearly an exception and it won’t happen again. Bottom line? We both won. I’ve used my pool for MS therapy an average of 120 times/year over the past thirteen years at my convenience and they saved a lot of bucks. At $200/hr. (probably more now), that equates to $312,000 of PT!!

This year, I won an appeal for a $1200 elevator lift on a new power chair. The lift was considered a luxury add-on, even though as a petite 5’3” person sitting, I couldn’t reach so many things in my house (like the stove and dryer knobs).

Small potatoes for them; big potatoes for me.

There is no question that we all need medical insurance today whether you have an existing medical problem or need protection from a possible future health problem. The exorbitant costs could leave an uninsured person bankrupt and out on the street in no time. With the baby-boomer population aging, our health care will be in real trouble if consumers don’t get involved.

Counting on our self-serving politicians and squabbling Congress won’t get the job done. But we can. Remember the Civil Rights Movement and the Women’s Suffrage Movement?

www.DebbieMS.com
Author/MS Counselor/Living with MS

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