Now, this isn't as bad as the woman who was denied her cancer treatment due to nondisclosure of acne when she was in her teens...but it is indicative of basic medical care being denied for no good reason. More below.
A very close friend of mine had a normal yearly exam with her GYN. A few weeks passed and she got a call from her doctor that most women fear, an abnormal pap. The good news, no HPV! Whoopie! The bad news Abnormal Glandular Cells were found. Which, apparently, is a rare result for a bad pap. And this particular result leads to cancer more often than other abnormal results. So, her doctor urged more testing.
So, she made an appointment to see her doctor to get a few tests done, a colposcopy, an ECC and an Endometrial biopsy. She decided to have them all done on the same day to not delay any results.
Her doctor does not take Anthem Blue Cross, but my friend, has a PPO, so under her plan, most (or so she thought) things are covered, not as much as if in Network, but she's not had problems before with claims. So, the procedures cost her $1175 the day of. The claim was filed within a few days.
Last weekend, she received her "reimbursement" of $92.35. That covered one procedure that was billed at $700. The other claims were denied with the explanation that it was part of another service that had already been reimbursed.
So, naturally, she called the insurance company to have them explain why this was the case. She gets someone on the phone, finally, apparently there was a lot of voice commands before a human actually took her call. She asks the woman, Lisa, why two of her procedures were denied. She looked it up and said that because the procedures were all done at once, they would only cover one. And that it was based on their negotiated rates with in Network providers.
My friend, naturally, was stunned. So, she asked the obvious question, had she done the procedures on different days, would Anthem have then covered them? .... Wait for it.....YES. So, they denied her claim based on SCHEDULING. In order for her not to miss too much work or more trauma than necessary physically and mentally, she had the tests done in one day. So, therefore, she's screwed on any reimbursement.
Since her rather upsetting conversation with Anthem, she went to Anthem's own web site to see how much the procedure they did "cover" costs. In network providers charge an average of $444 for the test they did cover that cost her $700. The low end charge that Anthem in Network providers charge is $269. With her plan, out of Network provider tests and health care are covered by a 50% co-pay, so by her calculations they are stating that the test costs only $184.70. They didn't even base it on their own admission of the minimum their own provider's charge for her reimbursement.
Anyway, just wanted to vent on behalf of my friend. She also had the pleasure of her rates going up 37% for their "service". She hopes that her tests come back negative and that HCR passes so she can leave Anthem.
She is going to complain to the insurance commissioner and have her doctor try to plead for help as well. But, she's not holding out much hope.
I am very much looking forward to Thursday's summit to see what the WH and Dems can do. I'm almost done reading the WH proposal now, which has some things in it that look to be able to help my friend and others like her.
I'm in the process of trying to leave my insurance company, put in an application the other day, I'll let you know how it turns out.
Let's get HCR passed.
http://www.thehamandlegsshow.com
UPDATE For the few of you who've written. My friend's test results came back negative. So, for now, she's in the clear. Still fighting to get reimbursed, but at least she is considered cancer free for now. Thank you for your concern. She really appreciates it.