spinergydude

Current location: Cambridge, MA
Current mood: bitter
Current music: "Tara Shakti Mantra", Oliver Shanti


raked over by medical insurance and physicians

So, I've posted related entries elsewhere, primarily my own blog, but I've just been abused big time by the medical insurance system, and needed to vent.

My wife's health is not good, hasn't been good for a long time. I married her in 1996 knowing that, but she was getting better at the time. Anyway, it turned serious the last few years, culminating in a doctor almost killing her. (Synopsis? She was going in for a procedure involving general anesthesia, and was nauseous the night before. She threw up at midnight, at 4 a.m., and while at hospital before anesthesia. Doc decided to go with procedure anyway. She threw up under anesthesia, aspirated vomit, and spent the next two weeks unconscious and at death's door because of ARDS.) I did not like this doctor. I did not like this other doctor. The first was a psychiatrist. The other was an internal medicine person. I complained. But my wife said they were helping, and, so, I could do nothing except refuse to pay, or to leave her, claiming I was no longer financially responsible, or go along. So, I love her. I went along.

I had medical insurance through my small business, bought through a group which did that kind of thing. The insurance I got was an HMO, all we could afford given my wife's health, especially for Rx. She also had Medicare, as secondary, or so we thought.

Indeed, it was secondary, according to the HMO, according to the group. Medicare went along. My wife had all kinds of special medical care, and psychiatric hospitalizations. In retrospect I believe the treatments the psychiatrist was putting her through were the cause of her condition and the hospitalizations, especially the mix of medications, a combo of powerful pain killers and psych drugs, plus ECT treatments, which is what she had when she aspirated.

So, 2006 rolled around, and she deteriorated, spending more days in hospital than not, of all kinds. Thusfar, all worked out, with the HMO being billed primary, then Medicare picking up the balance.

But come July of 2006, the HMO announced that they "discovered" they were actually secondary, because the group size was too small for a the special case of Medicare disability. This resulted over the course of half a subsequent year in the HMO withdrawing payment from all health care providers indicating they were secondary now. Medicare followed suit, since they now had to be primary. We're talking well over a billing churn of one million dollars, retroactive back to 2004.

So, decisions regarding affordability and billing in the first part of 2006 had been made, primarily by me, based upon the original claimed situation, advised by both group and by the HMO itself. After midyear, inquiries about whether things were fully covered were met with answers of "We don't know, the billing is unsettled because of the switch to secondary status." Finally, there was a point of concern in September, as my wife's hospitalizations continued where there was a question of having adequate numbers of days from Medicare to cover her hospitalizations. I was assured by the doctor and the hospital representatives that according to their records there would be sufficient days. See, I was concerned about that. They said my co-pay exposure might be $2000, and given my wife's condition, I thought that fine.

Given the thing which the HMO did, I insisted we quit it come 1st January 2007, with my wife getting an enhanced Medigap coverage, and I another plan, basically an HSA. But, then, the billings began. The hospital claimed that, after all the dust had settled, there were 45+ full hospital days which had no coverage from anyone. This was investigated, queried, quizzled. Now, finally, the bill is at hand, and we're talkin' $50,000 maybe $60,000. The psychiatrist says "Oh, I didn't know about the rules of the HMO" and "I was only counting psychiatric hospital days." They have sent the bill to collection.

So, our choices are:
Pay in full, and wipe out savings we've put together for a few years, and a safety net in case I lose my current job.
Ignore the bill and take the ding on the credit report, something which may have repercussions for my current job.
Try to negotiate some reduced payment amount and pay that, using an attorney. This is going to be tough if pursued, since the hospital and everyone has huge workload overages because of the billing and rebilling needed to handle what the HMO did.
Hire an attorney and file suit against one or more parties to get the money.
Any input from the Hive Mind? You can post here or at my blog on the entry linked at the top of this posting. If you'd like to send me your opinion off the blog record, post anonymously with your email address, and I'll get back to you, or use LJ's record of my own email to send it to me.

Thanks for any help.

Wonderment, ain't it?

>>>>>>>>>>>>>>>>>>>>>> I copied the entire post above so as to keep the content complete.<<<<<<


I am not a medical professional by the way, I am just a no one really. I just happen to know, well rather understand how the healthcare system is supposed to work... And, how it also abuses people. Like Aetna did with me.

OK, The HMO or Medicare one or the other should step up here. And, Medicare is also as bad as HMO private pay companies when it comes to these issues. I have the slight advantage to work for one of the countries largest non for profit research medical colleges, and hospital. I have advocated while at work for many people in this same boat. From home it is much harder. But, I want you to know I did it for me on 4-30-08 I was approved for my full Durable Medical Equipment as prescribed after I had medically proven my case...

First off I would request ALL information the insurance company has on you. That means all the communications notes they have in there data bases, and any recordings. By law they are required to send ALL of it to you. Should you have by chance kept detailed notes on dates, times, people, titles, and conversation content... You can better tell of they deleted something, and or left it out thinking you will never notice. This is very illegal to do, and they can not tell you that your not allowed to see that information either.

Same thing with the hospital. What this does is alerts them to the fact you know your rights. You rights as a customer, and your rights as a patient.

Next up the homework. If you thought you knew alot about your wifes medical condition before now, get ready to dive head first into tons more. Online is a vast network of medical documentation that is free for all of us to read, print, email and use. Google the condtion(s) your wife has, and locate medical studies, clinical findings, and support groups on those condtions. Locate MEDICAL SCHOOLS and see what is available to you. Find all possible treatment options as well, learn the side effects of each... Become the expert, as I am about my own medical needs. No person on Earth is as expert about my particular medical needs, condtions, and such as I am. DO NOT FEEL SHAME for feeling that you might know more than the Drs. do.

Now, keep a copy of this information in print, on your computer, and also an extra copy to take to people as needed, have them copy it, and you keep the original. This way, if say for example it is lost, forgotten or anything you still have it all at home. I have seen it all.

Make sure that once you get ALL of the information from the HMO, the hospital you go over it with a fine toothed comb. What your looking for are issues, errors, and such that do not make sense. I will use me as the example for you.

I was donated a wheelchair and well I could use it until 09/07 when I became fully disabled. Why couldn't I use it now? It was to heavy, improperly designed to make using it full time as easy as possible, and sitting in it was near impossible. It was a high strength lightweight wheelchair or a K4, or K0004 type. I had seen my Dr. in 11.07 in it he noted how horrid I looked and was in so much pain using it... Then in 12/07 In a loaner wheelchair like the one I would eventually end up being approved for... I was back and doing 100% better over all, still in pain sure. But able to function with much less, while i used a manual wheelchair. This loaner is a K0009 wheelchair or a customized ultralight weight wheelchair, or daily use wheelchair.

My Dr. in his notes I would later find called it a lightwieght wheelchair, not the proper daily use, or ultralight weight wheelchair. Now, it is unreasonable to expect any Dr. to know everything medical. I am my Drs. First full time wheeled user also. But, this little issue should had been caught by my insurance companies hired "Medical" staff a licensed nurse, or a properly accreditted Dr. and not someone else without those, as the denial had a nursed name printed by computer on it... That means nothing. Just that someone anyone could read the diagnisis, hit deny, and miss the many important details ANY medically trained person would have, should have noticed instantly. If this is the case leave a detail out, that you know about in advanced. And, if you ever need to deal with the HMO, and have someone on the line who can help, I mean the person is working with one of the Board of Directors like I was when I hot Aetna's 100% full and complete attention. Then have the layperson search something relates out, not on that page. When they point it out, state, yes I cam glad yo found that, I noticed it also... This means if two lay people reading this for the first time can find these issues... How did your hired medical staff miss it all? You did actually have a real live and fully licensed Nurse (in my case) or a accreditted mnedical Dr. in a related field to this medical condtion review this? I mean I would hate to imagine finding these medical issues, and taking to my provider, and or the hospital and they start asking you questions on how ethical your processes are? Or legal.

Now this proves that no one with medical knowledge has ever once looked at any of this information. So can you see why I do not think you had anyone review it with medical backgrounds?

And, do not be afraid to call your Drs and the hospital out on issues as well. Why? Simply because your making them aware you can now find the errors, the issues, and such that prove your case that they did not provide the best possible medical practice, standards, and such available today. In this case risking a life.

Now, once you get the information all in order, go in person or call or email, the Hospital Medical Billion Director, and explain any issues nicely. Always be polite and professional to all involved. As they can keep you from contacting them if they say your harrassing them. So no threats, no being mean. It wastes your energy anyway.

But, explain to this person any evidence showing they made errors, maybe wrong dates being billed when nothing was done. Or a asprin was charged at $30.00 and it really should have been ten cents, so then question the value and worth of all the other billed aspects of the bill.

Also, of they medically made errors, or such... No excuses are good enough, and the claim that this is a isolated, and rare mistake... No, it is not. They most likely are aware of most of the issues, and just hope no one does any homework. You can state: I requested all my information to gover the billing, and noticed these what seem to me, medical errors. Can we go over these now?

Once that is over, then share that you would like him to reduce the bill to a resonable for you amount. Or, to get on the phone, and with the medical evidence, clinical studies and all contact both insurance compaines and explain that certian medical, and legal issues have been brought to his attention, and the patient asked we resolve this quietly, out of the public light...

I does not matter how he states his plea to get them to cover what should have been in the first place. If he fails, and or flat out shoots you down. Do not get angry.

Instead, thank the persom. Stand if in person, or state at the end of an email or on the phone... Well, I thought I would at least see what you would be able to do. Looks like now my only option in holding a press conference and share my story with the local news and see if the community will take pitty on us, and donate the needed funds we just do not have...

Well thanks again for seeing me/listening to me/reading this... And, shake hands if in person one last time, hold it looking straight into the persons eyes, and not hard, but nice and firm a real handshake... Then turn and walk away, either right then, or a day or two later... Somehow something will have been found to help you...

Now, of course medical need is first to be proven, with out this, no insurance will cover it... Also, no one will care as much about the other issues if any...

Also, insurance companies NEVER pay the price shown to you. You can ask that it be reduced, to what the insurance company would normally pay. Now they can say no way, or may agree if they are worried that your only option to raise money is going public.

At no time threaten them directly with anything, as they know that most times people are angry, and upset... And, if you go public the people will hear about the near death problem and maybe other people died, and families seeing your story will get them fired up to fight the hospital and you might have a class action civil case... And, if any wrong doing by the insurance companies was found... Same thing with them... Absuing the system from either side is FRAUD. Or ABUSE. Two wrongs do make it right.

I stood up to Aetna, and after sometime to allow them plenty of chances to resolve things... I used my knowledge, knew my rights, and used pretty much this method to get a rather costly wheelchair covered.

The wheelchair priced for me to see was $4,100 plus total. Aetna will pay something like $500 to $1500 for it, and they only cover 80% I get to pay the near 1 grand out of my pocket. But, I can not complain, as I now am waiting for my wheelchair, it is being made to my fit right now, and by the end of this month I will be in my new ride. I worked out a payment plan with the DME reseller as I can not afford to pay that all at one time.

Why the hospital may decide to work with you after hearing your need to use the media to help raise funds... They may get grants from the local community for many things, they may also have a charity program they can use to help you, also they may get grants from the government and state you in... I am in NY, I work(ed) as a secretary at Strong Memorial Hospital in orthopaedics before I went out on full and permanent disabilty...

I appleid for and was denied SSD in 2005, and I appealed then. In 02/08 I finally was able to get the chance to sit in front of the Admin Law Judge... In less than 20 minutes he sent me out fully apporved. I got his notice, I wait for the letter to tell me how much I will be getting, and then I will wait for the actual award... This will be another year to finally get my first award and check from SSD... Never give up, never... I wish we had a savings account at all... Well, one we could fix the house, and sell it and move from Rochester to a warm climate... As people with chromic pain have been medically shown to improve in a warm stable climate. Medical science is lost to as why this is... I am not.

Wheelman,
Proactive Patient & Advocate