Thus Spake Zuska

As if the world needed another example of how the American health insurance system is completely insane, maddening, inefficient…I mean, we’ve all seen Sicko, right? But let me just share the private hell I’ve been through recently. I’d like to tell you what happened yesterday, but to do that, I have to go back a month or two.

In November my mother was hospitalized, and then spent time in a rehab hospital. During that time, she had a CT scan that diagnosed blood clots in her lungs. Medicare had approved my mother’s stay in the rehab hospital and, presumably, the treatments and diagnostic exams she received while there.

In mid-December I received a letter from the hospital informing me that Medicare had refused to pay for the CT scan because they said my mother was enrolled in a hospice. Would I please send them the address of the hospice, so they could bill them? I called the hospital, told them mom was not in a hospice, and told them I would call Medicare to straighten this out. I went through my mother’s Medicare statements and found other services with notations on them that Medicare refused to pay for them because, they said, mom was in a hospice.

I called Medicare. After wading through the byzantine voice menu, I finally got someone who told me that Medicare does not care if I am my mother’s power of attorney; Medicare has its own form that must be filled out and signed by my mother authorizing me to take care of her Medicare business. She would be happy to send me the form. According to her computer, it should be able to be mailed out to me on…January 6, 2009. WTF? I have to wait three weeks for them to even mail out the form? Isn’t it available on the web? Can’t I just download it and print it out? This request sent the women on the phone into a tailspin. She had to put me on hold and consult with a supervisor three times, before finally reporting back to me in triumph that yes, amazingly, the form WAS available on the web!

So I got the form, printed it out, filled it out, mailed it to mom with instructions where she should sign it, included a stamped, addressed envelope for her to send it off in, and waited. And waited. And waited. Last week, I finally received notice from Medicare that they had gotten the form and had deigned to grant me approval to handle my mother’s Medicare-related financial affairs. The same mail brought a $1400 bill from the hospital for the CT scan, with somewhat aggressive language about my need to pay it promptly.

I called the hospital again. I explained that I had just gotten permission to talk to Medicare about the bill and would call them that day. They agreed to put a two-week extension into the file.

I called Medicare. Why, I wanted to know, is Medicare acting like my mother is in hospice – when Medicare in fact forced her discharge from hospice in December of 2007? Why are they not paying for the CT scan and the other services? After 45 minutes on the phone and much digging in the records by a very nice and helpful woman, the following information was uncovered: (1) Medicare shows that my mother is not in hospice, was discharged from hospice in December 2007. (2) Medicare received a bill for the CT scan for $171 and made payment for it. (3) The other services I inquired about – all listed as paid in the Medicare records. Why am I receiving statements from Medicare saying Medicare refuses to pay for these services because mom is in a hospice? The nice woman on the phone had no freakin’ idea. She also had no record of Medicare receiving a bill for a CT scan for $1400.

I called the hospital again. I told the person on the phone there what I had learned from Medicare. This woman got a bit peeved at me, insisting that Medicare had rejected the claim because mom was in hospice and that the bill was for $1400. I asked the cranky lady – what am I supposed to do here? Medicare says they have no record of this $1400 claim, and that their records show mom is NOT in a hospice. Medicare says they paid for a CT scan claim that was filed in the amount of $171. How in the world am I supposed to resolve this? Cranky Lady said she’d go check the records again.

I have no idea what she found out, but when she came back, she was less cranky. She said the $171 was probably the doctor’s charge, not the CT charge (even though the statements I have from Medicare and Blue Cross show the hospital, and not a doctor’s name, associated with the $171, and even though it says “CT scan” next to it.) She said she would resubmit the claim with a note attached saying that Medicare acknowledges responsibility for the patient on the date of service.

I await to see what happens next. But really, none of the mysteries are solved. Why am I receiving statements from Medicare with notes about mom being in hospice, on services that Medicare has gone ahead and paid for anyway? How are these notes turning up when, according to the woman who looked, mom’s records with Medicare show she is NOT in hospice? If the records show that, then how was the claim from the hospital rejected? If the claim was rejected, why doesn’t Medicare have any record of the rejected claim?

So far this saga has required five phone calls to Medicare and the hospital; several to my mother to explain what she needed to do with the form both before I sent it to her and after it arrived; and hours of my time on the phone, printing out documents, filling out forms, searching through Medicare and Blue Cross statements, and trying to decipher those completely non-intuitive statements. And I still don’t know what the hell is going on, and the hospital still hasn’t been paid. This can’t possibly be any sensible way to run a health insurance system.

And through all this I keep thinking: what if my mother had no one like me to help her sort through all this? What if my family had no one like me – i.e., someone without a job – able to devote the extensive time required, often during working hours, for just one interaction with the health insurance system?

Then finally I think: And we’re among the lucky ones. Because my mother has really, really good health insurance. Doctors and nurses and office staff tell me this over and over when I interact with them on her behalf.

So, I know you’re very busy, President Obama, but if you wouldn’t mind fixing the health insurance system NOW, I’m sure we* would all really, really appreciate it.

*except the rightwing wackaloons for whom a non-byzantine health insurance system represents the end of civilization as we know it.

Comments

  1. #1 Becca
    January 21, 2009

    AMEN!
    Health insurance bureaucracy is the worst ever. I’m beginning to think it’s even more gratuitously convoluted than the tax code.
    Now I’m a little afraid for when my parents get on Medicare. Not that they aren’t perfectly capable of dealing with insurance (far moreso than I); but my Mom has perfected techniques for dealing with her union health insurance… I’m not sure anyone can be prepared for things like the situation you described. I mean, what can you possibly do differently?

  2. #2 b-ran
    January 21, 2009

    Health care makes me more angry than anything else I’ve encountered.
    I have a twin sister and we have the same prescription. We are both still students, therefor, we are still under our father’s health insurance plan. Every time one of us goes to the pharmacy, they tell us it’s too soon to pick up the prescription. The reason why is because EVERYTIME we fill that prescription, the insurance company puts it under the wrong twin’s name. We then have to wait an additional hour for the pharmacy to fill the prescription. It is SOOOO annoying!

  3. #3 FutureMD
    January 21, 2009

    Ever wonder why everyone working in the health system looks so frazzled? They’re tackling that system from the other side while someone vomits on them.

  4. #4 chezjake
    January 21, 2009

    Amen!

    And thanks for alerting us to Medicare’s demand for their own form for a health care proxy. My wife and I will have to see to that immediately; we have legal forms already in place designating our daughter as our proxy, but were totally unaware that Medicare would require a separate form.

  5. #5 je
    January 22, 2009

    And yet the argument I hear most often against a universal health service is that it’s too inefficient!

  6. #6 absinthe
    January 22, 2009

    Your story makes me feel ill. It is stressful to have an ailing parent, but, as a Canadian, I have no concept whatsoever of how much more stressful it must be to have to navigate this additional bureaucratic bullcrap. I am so sorry you are having to go through this.

    US politicians always seem to talk about socialized medicine like it is evil, evil, evil. Really? Canadians seem to like it just fine, and our country hasn’t self-destructed because of it yet.

  7. #7 usagi
    January 22, 2009

    One point: can we cease using (and correct those who use inappropriately) the caveat of “has really good insurance” in these cases. No, she doesn’t. If the insurance were really good, you wouldn’t have had to do this. The fact that you had to means that there’s a major flaw with her insurance. If we received service like this in any other area, we’d be screaming from the rooftops how horrible the provider is, but in health insurance, if it ultimately gets straightened out, we accept the lie that we have “good” insurance. No, we don’t–even those of us who do.

  8. #8 Zuska
    January 22, 2009

    Well, that’s sort of my point, Usagi – this is what the “good” insurance gets you. Many people don’t have insurance; many of those who do, have extremely crappy insurance. My mom has not terribly crappy insurance which, in the context of the U.S., is “good” insurance.

    I might point out here that the reason my mom has not terribly crappy insurance is because she is the widow of a UMWA coal miner. Her right to the insurance she has was won through collective bargaining. I don’t know where she’d be without the union.

  9. #9 Zuska
    January 22, 2009

    Chezjake, here’s the link to the Medicare form online that you need to get permission to deal with your parent’s medical info:
    http://www.medicare.gov/MedicareOnlineForms/PublicForms/CMS10106.pdf

  10. #10 Joel
    January 22, 2009

    I hope Obama and the Democrats in Congress get on this right away. Now that the economy is in the crapper, people are losing their jobs, and “good” health insurance, we need health care fixed now.

  11. #11 sandy
    January 23, 2009

    All that time on the phone with cranky, defensive “customer service” persons does wonders for the blood pressure.

    Oy.

  12. #12 stewart
    January 24, 2009

    In the US system, you need a dogged advocate – good of you to take it on, but often it’s the choice between fighting and bankruptcy. Unfortunately, like any private insurance system, it runs on collecting money, but not paying out until you have to, having minimally skilled administrative staff making medical decisions, squeezing providers to minimum costs (compare what the hospital charges medical for a CT scan versus what they charge the uninsured), and whenever possible, shifting the costs for procedures to another entity.

    Essentially, it’s sociopathic mess. If you need health care, you can’t get it, because you have a ‘pre-existing condition’. If the US bases its new system on any other country (ok, not Sudan or Somalia) it will be much better off. Just ask Sandra Day O’Connor, as noted here:
    http://delong.typepad.com/sdj/2007/09/sandra-day-ocon.html

  13. #13 Barbara
    February 3, 2009

    Zuska happens to be one of the smartest people I’ve ever met. I know there are a lot of equally brilliant people reading this blog…if she has had such difficulty, can you even imagine how the less brilliant among us handle such situations? The system is BAD, but a lot of the problems appear to be because of the inept personnel who are handling the claims. Insisting on speaking with a supervisor is always a good idea!

  14. #14 Joy Angel
    February 3, 2009

    Right at this time i am trying to find an health insurance with perscription coverage, vision, and dental all wrapped up in one package. I am on unemployment from a job that i lost due to health reasons. There should be a law against a person not being allowed to go back to their original job due to be let go because i had to have two surgeries back to back and healing up from one right now that i had on Dec. 16th 2008. If anyone knows of any program or package i can check out that’s not very expensive so i can pay for perscriptions and doctors and dental,vision. I am at my wits end right now trying to make ends meet cause i am still sick and need my job back once i can get my health back. Thank you
    Joy

  15. #15 etbnc
    February 4, 2009

    Medicare and private insurance: been there, doing that. Zuska, thanks for providing the link to the form you used. I was about to send a different one that probably would have complicated things further.

    Here’s to recovering enough of our collective national sanity to fix this craziness.

  16. #16 bnuckolsbnuckols@lifeethics.org
    February 9, 2009

    In Canada, this woman would not have received the CT scan.

    Y’all do realize that Medicare is the US equivalent of the Canadian system, don’t you?

    What you are asking for is more of this exact treatment, with the power of the US Federal law enforcement behind it.

    There’s a new Wall Street Journal Opinion piece, on access in Canada.
    http://www.freerepublic.com/%5Ehttp://online.wsj.com/article/SB123413701032661445.html?mod=rss_opinion_main

  17. #17 Zuska
    February 9, 2009

    Yes, yes, government run health care is Teh Evul. Because what we have now is so, so much better. As seen in Sicko.

    I’ve lived in one of those countries where health care is done much differently than here – Germany – and let me tell you, it was absolutely fabulous. You don’t lose your health care when you lose your job. Incentives for preventive care are built into the system.

    We’ve been brainwashed for years into thinking that we have such a frickin’ great health care system here when the reality is that what we have is so, so much worse than many, many other countries in the world. It’s downright shameful. And every time someone tries to do the least little bit of something to expand health care access or improve the system, we get the chain-rattling of “OMG, it’ll be just like Candadian health care!” We should be so lucky.

  18. #18 bruce
    February 16, 2009

    If the CT scan was during a Medicare covered nursing home or hospice period, then:
    (1) Medicare will pay for the “professional” fee in which a doctor reads the CT scan.
    (2) However, Medicare may expect the nursing home or hospice to pay for the “technical fee” which is the actual scan itself.
    (3) If this is the case, the patient is NOT (never) responsible to pay for the CT scan. The radiology facility must bill the nursing home or hospice.
    (4) GENERALLY when Medicare does not pay for a service like this, the loss belongs to the Facility and not to the Patient. It is usually illegal to bill the patient for a service denied by medicare. (there are exceptions but that is the general rule.)

  19. #19 bruce
    February 16, 2009

    i reread the statements. the medicare non-payment to the radiology center at the hospital, during a rehab hospital stay, would be worded very similarly to the denial for hospice. or possibly, she was coded as a ‘hospice’ benefit instead of a ‘rehab hospital’ benefit through error or some other reason. (For example, just imagine if the medicare hospice benefit was $1000 a week and the rehab hospital benefit was $800 a week; the institution taking care of her might slip a few cases in coded as hospice, just for money purposes, the extra $200, assuming no one would ever be the wiser.) But in either case, Medicare expects the radiology provider of the image component to bill the institution where she is institutionalized for hospice or rehab. another twist is that often families consider the stay as a “rehab hospital” whereas medicare considers it technically a 100 day benefit for: “rehab nursing home”.
    If they are persistent at the hospital to bill you, i would ask to talk to a Compliance Officer at the hospital who is higher than the billing clerk, after, having confirmed what i am asserting here by calling 1 800 medicare. you can also say that you have the hospital’s documents billing you, rather than the institution, and will report them to OIG (office of inspector general).
    The billing clerk would be confused because if the patient is “just” in a nursing home long term, they bill medicare, but if the patient is in a post-hospital, covered nursing home, the radiology center must bill the nursing home, which is the law, but both radiology center and nursing home will be annoyed and confused.
    if the scan is denied as “medically unnecessary” by medicare then NEITHER medicare or the patient owe the radiology provider. this is different than most private insurance, it is one advantage of having federal medicare insurance.

  20. #20 Zuska
    February 16, 2009

    Oh my god, thank you thank you thank you Bruce for all this information! Very very helpful!

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