This diary is about a long process of trying to get our insurance company, Humana, to cover administration of a life-saving vaccine to me and to my spouse. How do you win your case with a health insurance company? Persistence. Don't take no for an answer.
We had to discern what Humana wanted us to provide as proof of needing this vaccine (our doctor's order wasn't sufficient). S_____, our physician's assistant, spent more than 80 hours fighting with the insurance company. She called and faxed snail-mailed and and snail-mailed and faxed and called. During this time, S_____ couldn't do the other things she's paid to do for Dr P_____ because there are only a limited number of hours in each day. S_____'s persistence got us our vaccines, which may save our lives.
There was no "government bureaucrat" standing between us and our doctor. There were dozens of insurance company bureaucrats, clerks, secretaries, case workers, claim deniers, phone answerers, and the like, standing between us and our doctor. There was no government rationing of our health care - but there was certainly insurance company attempted rationing of our health care.
More below the fold.
The background:
We have rabid skunks (Warning: link is a video with bad language and partial killing of a skunk) in our state. We have rabid skunks in our county. We have rabid skunks on our farm. We have rabid skunks in our fenced yard. I have held rabid skunks in my hands (100% of our yard skunks have tested positive for rabies).
I have had no choice about any of those things - if you find a rabid skunk around here after 1 PM on Friday, you're SOL - the Health Department here closes at 1 PM on Friday, and the shelter doesn't handle wild animals, rabid or not. Even the animal control person here can't be reached after 1 PM on Friday afternoons.
Last year's rabid yard skunk was killed by our dogs on a Friday afternoon, and we had to make sure it was dead, bag it, and take it to the state diagnostic lab ourselves Saturday morning (no health department on weekends, either). When we took the dogs in for rabies boosters (an earlier trip on the same day), they weren't allowed inside because 2 stray dogs had died of rabies in our county that week. Not good. The critters all got their vaccines, but what about us, the rabid-animal handlers? It's just a matter of time before one of us gets chewed on by a rabid skunk.
The solution:
We need the human pre-exposure (before you get bitten) rabies vaccine. It's the same as the post-exposure (person already bitten or had contact with a rabid animal) vaccine, but the pre-exposure series is 3 shots per person, while the post-exposure vaccine is 5 shots per person. Why bother? Because if you get rabies, you die. There is one documented case of a human with rabies who survived. One. That's all.
Who decided that we need the pre-exposure vaccine? Our vet thought it would be a good idea. So did the state's rabies expert (also a veterinarian). So did our physician. So did we.
Who decided that we didn't need the pre-exposure vaccine? Humana stood alone.
We thought about requesting the pre-exposure vaccination last year, but a bit of research on teh Google showed that there was no pre-exposure vaccine available at the time. There was a vaccine shortage, and all the vaccine was being saved for post-exposure. We didn't want to request the post-exposure series, because even though we had certainly been exposed to rabies, we felt that the remaining vaccine should be saved for those actually bitten by a rabid animal. We decided to wait until this year.
The process, an exercise in aggravation:
First, Humana wanted a "pre-determination letter" requesting that they cover the shots. After hours of phone calls by S_____ and by me, trying to find out precisely what Humana wanted in this letter, Dr P_____ wrote and signed it. S_____ faxed it to Humana. According to Humana, it never arrived AND it had to be snail-mailed. So S_____ snail-mailed it. Twice. According to Humana, it never arrived. S_____ never got any confirmation of the letter's arrival, so I must assume that the post office (excellent around here) had delivery refused by Humana.
There were more phone calls by S_____. There were more faxings by S_____. There were even more phone calls by S_____. Finally, S_____ called me to tell me that the shots were approved (but she didn't get the name of the person who said "yes" - it was at least the 7th person she'd been transferred to on that call alone).
Two days later, I received a letter denying the request, stating that it wasn't covered as a routine vaccination (um... duh!). The letter was allegedly from the local Humana office, but the local office's phone number and address weren't in the letter. A Post Office Box number was provided with an 800 number that does NOT go to the local office. Since I doubted that everyone working in the local Humana office could fit into that PO box, I tried to get their local address. No luck. I tried to get their local number. No luck. I called the provided 800 number.
That number was a classic run-around. I never reached a human. I did give my name, address, policy ID number, and the nature of the call - 4 times. After an hour of this, I gave up.
I called S_____ again. She started the permission procedure again. She talked to dozens of (different) people again. She finally got high enough up the Humana food chain to talk to the head of their medical unit, Dr Mitchell (probably - I wrote it down and lost the note, but S_____ has it written down).
S_____ did some 'splainin' again. She did some faxing again. She pointed out that the pre-exposure vaccine costs $774 per person. The post-exposure vaccine costs $1290 per person, plus emergency surgical debridement (cleaning) of the wound, plus injection of rabies antibodies, plus possible in-hospital time for observation (if it's been a while since the exposure). The Humana physician paged Dr P_____, who explained it all again. Permission was granted. The shots were ordered. The first of the shots was administered a week ago Wednesday, and we got the second shots this morning. Finally. After 4 months. It should be noted that the office that finally OK'd the pre-exposure vaccine was the same office that S_____ had initially contacted, 4 months earlier.
For future reference:
The way to win a fight with an insurance company is persistence. LOTS of persistence. LOTS and LOTS of persistence. Never give up! Never surrender! I suggested to S_____ that she threaten them with our attorney (they don't care, but it wouldn't hurt). I told S_____ that if I could get an address, I'd bring them a skunk with rabies and ask why it was fine for ME to handle it, but not for THEM to handle it. (Calm down! A gift-wrapped box containing a stuffed toy skunk with a picture of the rabies virus IS "a skunk with rabies.")
If you can borrow S_____ to persist for you, do it - I don't know what we'd have done without her on our side. She's one of an excellent kind. As Dr P_____ said in an e-mail to me:
S_____ really did give this her all...too bad the system depends on such tenacity...I worry about people who don’t have a S_____ on their ‘case’ .
But even if you don't have S_____, keep up the pressure. It's no guarantee that you'll win your fight, but if you can keep pressuring your insurance company, they'll eventually spend so much in time and effort to keep turning you down that they just might eventually give in and cover what your doctor ordered in the first place.
S_____ said she'd given the pre-exposure vaccine before, years ago, but had never had a fight like this. Apparently, the talk of health care reform has caused Humana to dig in their heels and make as much money now as they can by denying everything they can, lest the ebil Obama make us all have good "socialised" health care (like everybody else in the civilised world has). Saving money and lives later doesn't count. Only making money NOW counts.
This makes me wonder what people mean when they say they're "satisfied" with their current health insurance. Are they "satisfied" because they usually (eventually) get their medical treatment paid for by their insurance corporation? Are they "satisfied" because they've never had a claim denied? Are they "satisfied" because at least they have insurance, and they're afraid to have none? Are they "satisfied" because their health insurance is paid for by their employer, so they've never had to face the real costs? Are they "satisfied" because they've never been dropped by a health insurance company (employer-paid health insurance is a group deal, so individuals aren't dropped, though employer expenses can rise dramatically)? Are they "satisfied" because they've never had to deal with a for-profit health insurance company's bureaucracy? Are they "satisfied" because they don't understand the difference between health insurance and health care? I've talked to a lot of people, and I don't know anyone who is genuinely satisfied with their private health insurance!
Oh, yeah, NEW RULE: People who have health insurance paid for by the government don't get to whine about "socialised medicine." This includes not only the 29% of Americans who get Medicare, Medicaid, or other insurance easily seen as government-paid, but also the millions who are paid by the government, such as police, firefighters, public school teachers, people working at state universities, municipal government employees, etc., who get health insurance through their employers and are therefore receiving government-paid health insurance.
The irony:
We just got a letter from Humana (actual motto in the return address is "Guidance when you need it most") extolling the virtues of getting a mammogram. On the front of the envelope, right above the window, was a customised printed line saying, "Don't Wait Until It's Too Late..." HAHAHAHAHAHA! I wonder if the author, Steven E. Goldberg, MD, MBA, Corporate Medical Director, Clinical Policy, Humana, Inc., 500 West Main Street, Louisville, KY, 40202, remembers enough medicine (around all that MBA info he had to learn) to understand that vaccination after the fact is already "too late." I wonder if he understands that his customers know that a positive test for breast cancer means he'll have them dropped from the coverage rolls. I wonder - how stupid does he think we are?