Thanks to Obamacare, a few of the worst practices in the for-profit health insurance industry have fallen by the wayside. The end of benefit limits for pre-existing conditions, lifetime caps on care, and required coverage corridors are among the most popular with consumers. But insurance companies are not the fuzzy, cuddly health care partners they portray themselves to be in advertisements. They are ruthless profit engines beholden to investors to maximize revenue and minimize cost.
One of the best ways to minimize cost is to minimize claims. And despite the protections now in place thanks to the Affordable Care Act, our for-profit healthcare industry still finds dastardly ways to shortchange doctors, hospitals, and patients alike.
Below the fold are two brief personal narratives, offered here merely as generic examples of the shenanigans insurance companies still play on their customers. Care has been taken to present only the facts, but take both stories with a grain of salt: I am not a veteran insurance adjuster with billions of dollars in resources behind me. In several cases while researching the more egregious of the two stories, I saw officially signed correspondence from the insurance carrier stating a simple fact about coverage, only to be subsequently told both by customer service via phone and in an official authorized letter that the prior letter was wrong and they had changed their mind. Facts are slippery things when it comes to health coverage. With that, let’s dive right in, and feel free to offer you own health insurance nightmares in the comments.
The first case involves the lady I wrote about last week—let’s call her Mina—in an unrelated story about HOAs. Mina is a middle-aged single mother who came down with brain cancer almost three years ago. Her initial prognosis was as little three to six months to live, and those months would mostly be spent in a hospital. As it turns out, some patients will beat the grimmest odds and she was among them. But the side effects from brain surgeries, chemo, radiation, and massive corticosteroids almost killed her on at least three separate occasions. She ended up wheelchair-bound and suffering from a variety of neurological deficits including left-side paralysis and left-side visual neglect.
The recovery process has been exhaustive of course, but worth it: She’s since regained a lot of mobility. A few months ago, with the help of a cane and friends close by, she was able to limp through a full mile in a local cancer awareness event. One of the key factors has been massive amounts of inpatient and outpatient therapy, typically lasting two to four hours a day, three to five days a week—Mina trains and diets with the intensity and focus of a professional athlete. Most of that therapy originally took place at a local hospital in Austin called St. David’s. It gets pre-authorized by her carrier, Aetna, six months at a time. In mid-2015, her second six-month stint was duly authorized. Both she and St David’s received the authorization letters and completed that regimen.
She was in her third stint when she received a letter stating that upon review, that second six-month stint was not covered after all. In lay speak, Aetna officials had changed their mind after the fact, and she now owed St. David’s more than $20,000. St. David’s is on her side—they never would have seen her for six months without clear authorization. And there is no glaring omission or any funny business going on here that I’m glossing over. This is what really happened: She was approved for the sessions, completed them, and then Aetna unilaterally changed their mind about covering them after the fact.
She is now in the appeals process, but just getting a straight answer as to where she stands in that process has proven needlessly elusive.
My own case is far less disturbing but probably way more common. Not long ago I broke a bone in my foot. I heard and felt it crunch when it happened. The accident happened at home late at night, and I knew an X-ray was needed. I also knew if I waited until morning and went through Aetna to make absolutely sure I followed in-network procedure to the letter and used an urgent care facility instead of a full-blown hospital emergency room, it would save me time and money. The next morning I got through to customer service at Aetna. They advised me to go to the nearest in-network minor ER, which they even looked up and gave me directions to.
I arrived at that facility only to find they were permanently closed and had been for months. I called Aetna back, asked for another option, and they gave me the nearest one several miles away. It took almost an hour to find it, and when I finally did the front desk told me that as of January 1 they were no longer in that network, and they wouldn’t even take my insurance out-of-network.
By now it’s been more than 12 hours since the injury. I’ve been driving for three of those hours with a throbbing, black and blue, grossly swollen foot. I just started stopping at any minor ER I saw, and the next one told me the same thing the last one did: They won’t accept Aetna under any circumstances. On the third try I got lucky and they accepted my insurance. I got the X-ray and sure enough, the metatarsal that turns into the toe that had roast beef is cracked. It was set and I was on my way, stopping only to pay what I thought would be a $75 copay. At that point they told me that hospital was not in-network, but they would process it as an out-of-network claim.
That means first they bill my carrier, then me for the remaining balance. I called Aetna yet again, explained what happened, and they spoke to the ER’s office manager to try and code everything right. But the point is, I don’t know how much more I could have reasonably been expected to do, and odds are I’m still going to get hung out to dry. In fact, attempting to do it right was probably counterproductive: For all I know, the bill could easily top a couple of thousand dollars on this deal. It might have been cheaper—and certainly faster—to go to a full-blown ER and bite the $250 copay bullet.
Every single health care consumer has these kinds of stories, or will have one sooner or later. Somehow, with all the might of billions of dollars and decades of experience behind them, insurance companies constantly “forget” how to keep track of accounts receivable and payable. So the patient, often suffering severe injury or disease, has to call them up and remind them to pay.
Knowledgeable friends tell me that Aetna will probably pay something, sooner or later, in both Mina’s case and mine. But they haven’t yet and where it will leave either of us when it’s all said and done is anyone’s guess.
The ACA helped tremendously, making health insurance affordable for millions. Equally important, Obamacare made sure insurance companies can’t weasel out of benefits as easily as they once did. And no doubt there is room for improvement.
But there’s also room for many steps backward. What’s chilling to anyone with a pre-existing condition or in the middle of battling a deadly disease or injury is the conservative obsession with “repealing every word of Obamacare” and replacing it with nothing. If you think there is no real difference between the GOP and Democratic presidential hopefuls this year, I beg you to reconsider: For many, the difference is quite literally life and death.