Saturday, June 26, 2010


Raise your hand if you think you can properly interpret your health insurance policy. I didn't say Simon Says. Put your hand down. You're out.

As I wander helplessly through the bureaucratic maze of explanation of insurance benefits, or more precisely, lack thereof, I feel like I am in the middle of an Abbott and Costello who's on first routine. Let me walk with you as I take you on a journey through the who, what, why and I don't knows.

It all began innocently enough. As a result of back surgery last June, I was in need of some physical therapy. Having done nothing over my lifetime to 'strengthen my core' I would now go through several months of sessions, 2 or 3 times a week, to at least try to build a one or two pack. The goal was to give me the best chance of keeping me upright and out of pain. Logic would dictate that this would help me and ultimately benefit my insurance carrier, who would not be faced with paying for any additional surgery.

My insurance plan permitted me 30 visits per year with a physical therapist. My cost, were I to find an in-network back strengthener person, was $20 per session. The carrier would then absorb the remaining balance, at a rate agreed upon between them and the service provider. Simple enough. And simple enough it was, as I located someone who was willing to accept what seemed like a wholly insufficient payment from my carrier (I think the total compensation was $59 per hour). I got to be pushed, pulled and prodded, and in the end, was without a one pack, but thankfully in little discomfort.

Come early December, my back had decided it was not through causing me pain. A trip to the doctor resulted in a prescription for 12 more sessions with a therapist of my choosing, as long as that person was in network and agreed to accept the payments established by my carrier. But, since I had exhausted my 30 permitted visits for 2009 and would now be paying fully out of my own pocket, at least for the balance of the calendar year, I would wait until the ball dropped before I began dropping and lifting the ball in the therapist's office. I was smart enough to understand my policy terms. I would be patient until I could become a virtually non-paying patient.

And wait I did. In early January, armed with a brand new bag of 30 allowable visits, I searched out a new therapist,as I was concerned that my earlier course of treatment had actually been a little too easy on me. It seems my carrier was known for being particularly stingy, so my chore was not as easy as one would imagine. But, eventually, I found a practice that advised that I, and my carrier, were welcome. I was told I could start with them as soon as they were in contact with my carrier, and had gotten the approval to take care of me.

As it turned out, take care of me they did, but not as I had imagined.

I was informed in the middle of January that all was set and I was now their patient. At the first of my sessions, I checked in at the reception desk, announced myself and my intentions. I was led shortly thereafter into the back room, which looked much like the room where my 2009 treatments had occurred. Things to pull, things to push, things to run on, things to lie down on, alarm clocks, timers, and other people in various states of disrepair.

I was 'assigned' to my leader who gently walked me through my paces, seeing where I was, and where I would eventually go. At the end of our 50 minutes (the shortened version of an hour) I went back to the front desk and advised that I had a $20 co-pay that I would now fork over. I was then told that I would be separately billed and thus I should put my $ back in my pocket. I did.

I ended up going back to this facility on 10 additional occasions. I liked the treatments, well at least I thought they were helpful. Each time in I passed the reception desk. At the conclusion of each session, I went back to that desk and got a token, which permitted me to leave the parking lot without cost to me. It was a seemingly efficient system and it was as pain free as these things can be. Never once was I asked for any money, and never again had I offered. I was waiting for my bill, which by my calculation (not too difficult to do) was to be $20 times 11, or $220.

So, you can imagine my surprise (that it the "g" rated version) when a month or 2 later I opened up my insurance carrier's explanation of benefits to discover that I was being told that MY cost for these 11 sessions was somewhere north of $2700. The first question I had to ask myself was how the carrier decided that my therapy, when they were paying it, was worth less than $60 per hour, but when I was reaching into my pocket, the retail value had escalated to over $300 for each 60 minutes (including the portion that they pay). Bad enough. What was unfathomable was the next leap into the world of the illogical.

The therapy practice had 2 offices, one located somewhere out in the general community. The second, where I found myself due to its proximity to my office, was housed in a wing of a local medical center. This, I was now being advised, made me a patient at a hospital. It apparently mattered not that I walked into each session from the street, and 50 minutes later walked out through the same door I had earlier entered. My 30 treatments, with my $20 co-pay, no longer applied. Now, my $2500 deductible for hospital visits controlled.

My son is both very bright and very much engaged in the practice of dealing with insurance carriers and hospitals. He has had the misfortune of being the go to guy to address our family's insurance questions, whether pertaining to himself, to his sister, his parents, his grandparents, and on occasions, various other members of society. I turned to him, sure this would be a slam dunk. Not so fast.

He started using words like interpretation and phrases like 'exploiting a loophole'. He spoke of working its way through the system. How could this be?

We have since had conversations with the carrier and the therapy center. We have written and explained. We have received assurance from the therapist that they had spoken with the carrier on the day of the first treatment and confirmed the $20 copay. We are still being billed for the full amount by the therapist. We are still being told by the carrier that this is all my responsibility. We are nowhere close to resolution. I do not know whether this will ever lead to a rational conclusion.

I don't want to pay this bill. I am not obligated to pay this bill. I pay an exorbitant amount of money every month for insurance protection. I have insurance but little or no protection. I don't want to be dunned. I don't want my credit impaired. I don't know why what seems to be so clear is not. I want to get out of this Abbott and Costello routine but I am afraid I can't find the exit. All I know for sure is that I don't know much about my health insurance. Except that it went up 34% this year.


Anonymous said...

Most of us seem to be in the same boat and the rates keep going up every year. Something is very wrong here. Hey Abbot !!!!!!

Jeff C

Anonymous said...

Maybe I'm naive, but I hope you can get away with being a little aggressive. Talk to the person who deals most with insurance at whichever office of this practice and nicely explain how you had told them about the $20 copay and were not informed of a problem. You cannot afford the $2700 and would not have undergone the treatments if you knew they would be so costly. Furthermore, the same treatments at their office would only have cost you $20 each. Good luck!