March 11, 2010

My Insurance Story

For all of you that stopped here in hopes of a horror story about private insurance just keep looking this is not that story.

My condition (fibrous dysplasia FD) was first discovered by the Veterans Administration (VA) in 1993. Interestingly enough once I turned 21 my records were conveniently lost. The VA would forever be responsible for my care if the records existed. I did not see another doctor again until 2005 due to my dislike of the procedures the VA offered. These details can be found in other posts.

By the time I went back to a doctor I was insured on my wife's private insurance. In the past three years I have visited multiple specialists and have received many perscriptions and in all this time I have only had three refusals of payment from the insurance company. Two of these were for perscriptions and the insurance company recommended a different brand of the same drug that they would cover. The recommended drugs were the exact same as the one my doctor had ordered but they were not as expensive.

The only other time I had a refusal it was easily fixed. The issue occurred when I applied for Social Security benefits (which were denied because I spent too much time trying to work instead of just applying and not trying to make it on my own for years). The Social Security Administration denied my claims but generated paperwork that made it appear to my doctors and then the insurance company that I had another primary insurance. This meant that my insurance began to refuse claims because they were no longer listed as the primary insurer. This fix was as simple as cutting butter with a hot knife; I called the insurance company and described the problem. The customer service rep looked up my information and confirmed the issue. She then asked me to hold for about five minutes. When she returned to the line she informed me she had fixed the data in their system and resubmitted the claims. Problem FIXED.

When it has come to specialists I have never received a refusal. As long as I assure the specialist is in network my costs have remained low and I have always been able to find a highly qualified specialist. 

A little over a year ago I had a major surgery and the insurance company approved the surgery and paid for everything. Now I know my wife did call the insurance company and do the pre-certification herself. She tells me this is because even though the doctor and the hospital are in network the anesthesiologist and other medical staff may not be participating in the plan. She always calls on the per-cert herself and does not leave it to the surgeon because when she calls the insurance company walks her through everything and then she knows what is covered and what is not covered. In our case the surgical assistant's full price would not be covered but he was willing to take the insurance negotiated amount so he could work with the surgeon. As noted in the past these little steps of directly working with the insurance company have always allowed us to get the services we need while keeping costs low.

On the other side of the issue I know multiple people that have struggled through care at the VA. I know consultants that have been hired to work with the VA to improve care. In one case I know of a VA project that has VA staff and the staff of two consulting firms working on outsourcing veterans care to private hospitals so that the veterans receive better care. I know of people that finally paid for their own surgeries because the VA refused to allow surgery even though their doctor recommended the surgery. I know of one man that had to fly from CA to CO to get a routine preventative test because the CA hospitals could not get him as soon as the VA insurance demanded he receive the test or lose benefits. I know of multiple people that have had to have scans and services done multiple times because their files have been lost.

My personal experiences make me unwilling to place my private insurer on the gallows so if you want to hear a story about private insurance abuses I am not the man to ask.

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