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Monday, September 29, 2014

Not-So-Fantastic Voyage: My recent insurance odyssey

Monday, September 29, 2014 By

AUGUSTA, GA - I'm lucky to have excellent insurance - expensive insurance, but excellent.


Accessing those benefits can be more difficult that I had imagined. Come along on my journey that took place just a couple of weeks ago.

Emerson had complained about mild stomach pain for a couple of days. We treated it at home. Then one day, it wasn't so mild. Uh-oh. I called the doctor.

Only they wouldn't see her. No openings that day.

So I took her to the prompt care place that we have used for five years.

Only they wouldn't see her.

"We're not listed as her primary care physician," the desk clerk said to me. "It's an HMO, so they'll have to approve that change."

Commence epic phone call to Blue Cross Blue Shield. The wonderfully friendly customer service rep was happy to change Emerson's primary care physician... once I got her on the phone. Long hold, many numbers punched in, several false starts due to the automated voice recognition system picking up Emerson's incessant chatter in the back seat, then the system accidentally hung up on me, commence another long hold, etc.

My phone was dying, when finally she says, "Hmm. I'm finally where I need to be in the system, but I'm getting an age error."

"An age error?"

"Since she's under 15 years old, it says they won't treat her."

"But... they've been seeing her since she was four. They diagnosed her and treated her for pneumonia," I said, confused.

Then came another hold. Blarg.

Ten minutes later, she was back: "It looks like he changed his contract in July of this year."

Oh, great. Would it have killed him to send a letter?

"Well, thank you for investigating that. I really appreciate it. But I still need to see a doctor. Her primary care physician can't see her today. And, obviously, this place won't take her. Can you give me another idea?" I asked.

They sent me to another prompt care place 15 minutes away. "They're the first recommendation on the list," the rep said. Great!

Only they wouldn't see her.

"We don't take that insurance," the desk clerk said.

"But... my insurance company is who recommended you," I smiled. This was getting kind of ridiculous.

"No, we don't take that insurance."

"I'm... I'm... confused," I blinked, and tried to keep smiling. "Can you help?"

"What help do you want?" she asked, giving me the side eye. "We don't take your insurance."

"I guess I'm wondering under what circumstances my insurance company might tell me that you're a provider, when you're not. Is there maybe a practice with a similar name that might be the source of confusion? Or... something?" I stammered out an answer that was nowhere close to what I wanted to say.

She gave me a hard look, "We are not responsible for misinformation your insurance company provides you, ma'am."

Oh. She ma'am-ed me. And invoked "responsibility." I wasn't going to get anything further out of her. I could see her making a mental note of me as a "problem."

Just then a colleague of hers leaned into the window.

"You have an HMO, right?" she said, brightly, with a smile on her face. "We only take Blue Cross Blue Shield HMO patients if their primary care physician is a part of this health care system."

Do what?

There was no point in discussing it further. I kept my smile plastered to my face - hopefully they didn't notice the Crazy Eyes that went with it - thanked them for their time, wished them a good day, and carried Em to the car. Her stomach was hurting again.

In the car, I called the insurance company again. Cue the long wait, the multiple menu items, the false starts, etc.

"So, I'm out of ideas," I told the rep, trying to keep a cheerful voice so she'd want to keep talking to me. "My daughter needs to see a doctor today. She's in pain. The first prompt care place you listed for me won't see her anymore, and the second doesn't take the insurance."

"What do you mean they don't take the insurance?" she asked.

"They said they only see HMO patients if their primary care physician is an employee of their health care system," I explained.

"Well, ma'am, we can only give you the information that is listed in the system," she said.


"Yes, ma'am, thank you. I can appreciate that. I guess what I would request is that you flag the practice, or make a note, and perhaps someone can investigate this misinformation."

"We have no way of knowing that we're giving out incorrect information," she said, defensively. "The doctors update their information in the system, themselves. We go by what they put in. We would have no way of knowing if it is not accurate."

Great. Now she's offended AND I'm no closer to getting my child to a doctor. I smear a smile back on my face and hope it conveys through the phone line.

"I didn't mean to imply that it was in any way your fault, or that anyone at Blue Cross is not doing an excellent job. I've only spoken to super nice people today, who have gone out of their way to be helpful. I guess my concern is that I work for an organization with 13,000 employees in this area. We're all pretty much insured by you. If that is your number one recommendation, how many other customers are being misinformed? That's not your fault, of course. But maybe it wouldn't hurt for someone to follow up with the practice?"

"I guess I can tell my supervisor and maybe she can do something," she said.

"I would really appreciate that," I said. "Thank you."

"So as for other urgent care practices, I have only one more on the list that you haven't tried," she said, naming one I had previously used and to which I wouldn't take a stray dog. Their unprofessional attitudes in dealing with patients seriously made me question the quality of their patient care. Because whatever specialized education and training medical practitioners have completed, let's be clear: It's still about taking care of people. Listening to them.

In fact, in a study I read (okay, I reviewed a summary) some years ago, family practitioners said that a large part of their diagnostic tools boiled down to the conversations they had with their patients. This practice is incapable of listening. So, in my mind, they are incapable of doing their jobs well enough for me to entrust my child to them.

This is where things could have gone totally wrong. Because, essentially, I was refusing to walk through the open door they had presented me. She was out of options for me. She suggested that I call the primary care provider and ask again. She had tried. I couldn't fault her for my unwillingness to try her final attempt at a solution.

So I called the primary care provider again. They still couldn't fit us in. But Jill, the unlucky medical assistant who answered the phone when I called, suggested that I call another branch of the practice, where Emerson had previously been a patient. We loved that branch, but shifted care when it became geographically impractical.

"They have her in the system as a current patient, and they can fit her in today," she confirmed via their shared database. I could have kissed her on the mouth. What an easy solution to our problem!

Then I called that branch. Let's just say that the level of customer service did not live up to my expectations. The person who answered the phone was... unenthusiastic about her job. And then disputed what Jill had shared with me.

Well, I wasn't going to allow her to call my new best friend Jill a liar. So she spoke with her supervisor, who verified that they couldn't see Emerson that day. Although I'm not entirely convinced that she didn't just put me on hold and file her nails. Anyway, she said they couldn't see Emerson until about three weeks later. She suggested that I go to the E.R.

Now, look, the E.R. is lovely. We've been there before. But it's not a primary care office. And, frankly, with so many doctors supposedly worrying about attracting and/or keeping patients who are insured by anything but the Affordable Care Act, you'd think she'd find a way to squeeze in a sick 9-year-old who had been a patient. But, no.

I didn't know what to do. A $100 co-pay at the E.R. was looking pretty good right about then.

But I made one final phone call to Jill... who doesn't know that she's my best friend in the whole world.

"Hang on a minute," she said. And put me on hold. The hold button and I were becoming dear friends. (It's okay, Jill, I still like you best) Then she came back on the line. "Turns out, another doctor had a cancellation. If you can get here right now, we can fit you in."

Y'all, I didn't even know that my hatchback had rocket boosters. But it totally does.

We waited less than 30 minutes, paperwork and all. They whisked us back, and we waited less than 10 minutes to see the doctor. This doctor was awesome. Kind, intelligent, blunt in a way that let me know she was not messing around about our daughter's health. Here's one exchange:

Her: "How much sugar does she eat?"
Me: "Oh, I regulate her sugar intake pretty well."
Her: "Okay, now much sugar does she really eat?"
Me: "Way too much."

Then we were done. Prescription written. Problem solved.

What's the moral to this odyssey?

First, the way insurance companies do business is actually causing pain, discomfort, and anxiety to its customers, because it is putting up unnecessary barriers to adequate medical care.

Yeah, this story is anecdotal. But it's a scenario that plays out in various versions throughout the country on a daily basis. Insurance companies routinely deny claims that they cover, because a certain percentage of people don't realize that they're covered for the thing that was denied, or can't navigate the labyrinthine appeal process. Insurance companies sometimes demand "prior authorization" before treatments can be approved, despite the fact that 95 percent of their employees have little to no medical training and are wholly unqualified to deny or approve any medical treatments, whatsoever.

Second, persistence pays off. I picked up Emerson from school at 10 a.m. She saw a doctor at 4 p.m. If I hadn't been persistent, she might not have been seen for days. As it turns out, it wasn't medically necessary for her to see a doctor immediately. But I had no way of knowing that. That's what doctors are for.

Anyway, at no point did I lose my temper with anyone, or speak harshly to them, or insult them, or cry. I wanted to do all of those things, and I would have been justified. But it would not have been a good model for Emerson. Being a bitch about the situation wasn't in her long-term best interest. Although, I think being a bitch is not necessarily a bad thing.

But there are other ways. In any darkened, closed system, there are gaps though which light shines. And many of those gaps are beautiful humans. You just have to find them.

"You know, when it's an elderly person or a child, you just find a way," one of the medical assistants cheerfully told me when I praised the staff and thanked them for getting my child in to see a doctor that day.

It would be inappropriate to tell you where Emerson and I go for medical care. But let's just say there's a multi-branch center of primary care physicians who will have my loyalty for life. I highly recommend them.

Unless they fail to attend to my child. Then we'll be out like a shot.


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