If You Like Your Health Insurance

(Photo Detail:  The auto ferry to World Heritage Site, Fraser Island--Australia)

If you like your health insurance plan, you can—wait a minute!  Is there anyone out there that actually likes her health insurance?  I’d like to meet her.

I mean I guess you could say I’ve always liked my health insurance “plan.”  The problem is that it is delivered to me by an actual insurance company, and I’ve never met one of those that I like.

I think most people would have just gone ahead and paid the 19 bucks.  But it’s the principle--and the fact that I’m two and one-half hours into this project already, I’m not giving up now.  Furthermore, I think that’s exactly what they are counting on—in fact, I think that’s part of the business strategy of health insurance carriers.  Most importantly, I pay Blue Shield $879 each month for health insurance—I think they can afford to pay $19 when they are supposed to be paying it.  If only they didn’t make it so hard.

I’m not trying to single out Blue Shield.  I used to have Aetna and had to fight for every dime with them too.  That’s why I think it’s built into the business plan.  In fact, it’s about the only business I can think of where the company providing services doesn’t have to treat you very well because they know there’s nothing you can do about it.

I was just at my bank last week getting a document notarized.  They were so nice to me.  We had an appointment, for which our banker was right on time.  She smiled and made pleasant small talk.  She even asked how my day was going so far.  Unfortunately, I had just been on hold for an hour and 15 minutes with my insurance company over a stupid $19 dollar charge, so I think she’s sorry she asked.  But she didn’t act sorry that she asked; she was really sympathetic.  And she gave me a lollypop from the bowl sitting on her desk.

The bank knows I can go to any bank, so they try to be nice to me.  Even when Doug calls our cable company to cancel HBO or Showtime because it’s too expensive, they try and do something nice for us, like letting us have it for another six months for only $10 a month.  When we were in LA last weekend, all the people at the hotel were really nice, they even sent up a bottle of champagne to our room because they had it in their records that it was Doug’s birthday this month.  They know there are many hotels we can choose from, so they need to actually do something to earn our business.

Not so with the insurance company.  I’m not saying they are not nice, I’m just saying they really seem like they want to make it as hard as possible for me to receive the service for which I am paying them $879 a month.  I didn’t mean to imply that the individual people are not being nice to me.  It’s just that the institution itself seems to be against me.

Last month, Doug and I went to get our first-ever flu shots.  By the way, we chose our health plan specifically because it was the only insurer whose network covered our wonderful, local medical facility.  So we made a date of it, off to lunch and then to the clinic for shots.  The experience did not disappoint.  All of the parking right in front of the entrance says, “Reserved for Patients Only.”  How about that for customer service?

Then when you get off the elevator, there are two smiling silver-haired volunteers to point you in the right direction.  They warned us there would probably be a line for flu shots.  But then there was no waiting at all!

I told the nurse I had never had a flu shot before, so she took a few minutes to tell me all about it and what I might experience in the next couple of days.  All in all, it took about 10 minutes.

Unlike my old individual high-deductible policy, my brand new ACA-conforming policy now covers flu shots 100%.  BUT ONLY IF YOU CALL THE  INSURANCE COMPANY AND WAIT ON HOLD FOR AN HOUR AND FIFTEEN MINUTES.  And even then, you still have to jump through a few more hoops.

When we got the bill for our two shots, the service to inject the shot for $31 was covered for each of us.  But the $19 charge for the actual vaccine was applied to our deductible. 

So I called our doctor’s office and they said they didn’t know why the vaccine wouldn’t be covered.  It should be covered as preventive care just like the cost to inject it into our arms.  The billing department referred me to my insurance company.

So then I waited on hold for an hour and 15 minutes.  The agent, who was perfectly nice, looked into it and told me that the hospital coded the vaccine with the wrong billing code.  He couldn’t tell me what the right code is but he said the provider would have to re-submit the claim with a “preventive diagnostic code.”

So I called my doctor’s office back and the billing gal said it was coded with a preventive code:  V04.81.  I’m not an expert in billing codes, so I just have to take her word for it.  So I asked if she could tell me the code for the $31 charge that was covered, and guess what, it was V04.81!

So, when the Blue Shield agent called back to answer a question for my husband on his prescriptions charges, I hijacked the phone.  I told him what the billing department told me, and he said they did not use the correct code, but “if my healthcare provider was unwilling to help me,” he would take matters into his own hands and override the charge.

Yesterday, the billing supervisor from my hospital called to say that she had also looked into the matter and the code was indeed already correct.  She was going to “escalate” the matter and call the insurer directly to handle it for us.  I’m happy to get out of the middle of this, since I wouldn’t know the difference between a billing code and a building code. 

It just seems to me like at the very front end, my insurance company should have had some person that looks at the bills and says, “Oh my goodness, this is for a flu shot, and logic tells me that irrespective of the code that was used, I’m so smart that I know a vaccine and a shot go hand in hand, so we will cover the whole thing.”

And if an agent does have the ability to override a charge, shouldn’t they do it the first time I call, after I have waited on hold for an hour and 15 minutes, and before I talked to my doctor’s office two more times to find out that each one is pointing the finger at the other, neither responsible for the fact that I’m being billed $19 for something that should be covered by my $879 monthly premium?

Unfortunately, this experience is nothing new.  Even when I had a great insurance plan at my former employer, I spent hours and hours on the phone fighting for them to cover the stuff they were supposed to cover.  I suppose the good news is that now that I’m retired, I have the time to hold them accountable, even for a tiny $19 charge--something I simply would not have had the patience for when I was still working.

(For a really great read about trying to find out the price of a medical procedure in New York City read this Wall Street Journal article.  Its author had to make 46 phone calls, was placed on hold 56 times, and wound up with 19 pages of typewritten notes—only to receive price quotes from 6 of the 10 hospitals she contacted.)

Related posts:

            Comparing Health Insurance Deductibles

            Health Insurance for the Early Retiree

            Shopping for Health Insurance on the Exchange

 

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Comments

[RJ]

You gave a long but totally recognized story here Syd. Now that I am on a single payer Medicare plan I don't have to jump through all those hoops. I pay a little less than $400/month to get basically a paper-free and deductible free healthcare.

It is well documented that the vast majority of private insurance efforts are geared toward not paying for things. Their exceptions are wide and tragic. If only they put the same energy in helping their customers instead of fighting them for every dollar....

Thanks for giving us this humorous (although I am sure you were not laughing at the time) story about your adventures into the for-profit healthcare industry..

[Cyclesafe]

Sigh. Same old, same old. I fully expect to fight the insurance company for every payment / reimbursement. It's part of the cost of health care. No point of wasting energy hoping it should be any different.

[Retired Syd]

RJ: If only this were my only story like this! Unfortunately, I've had a million of them just like this over the years! Only 15 more years until Medicare . . .

[RJ]

I know the story Syd. I too faced it for thirty years. One of the last rounds was when they didn't want to pay for a test that in the end saved my life. They called it experimental even though it has been performed thousands of times.

Maybe we will eventually learn what the rest of the world knows already and move to a single payer system before your fifteen years are up.

[dgpcolorado]

I've had good service for flu shots from a Target store pharmacy. When I was there in September I saw a sign about the (expensive) shingles vaccine and noticed that I am now at the recommended age. So I asked about it and the pharmacist checked with my insurance company (Anthem), found that it was covered (thanks to ACA preventive care requirements I believe), and gave me the shot at no cost because it was paid for in real time by my insurance policy. A few weeks later I had the flu shot, also at no cost. Whether it will work as smoothly with my new insurance company, chosen on my state exchange, remains to be seen, but I presume so.

Perhaps it works differently in California, but you might want to try getting vaccines at a store pharmacy and skip going to your local clinic and dealing with billing issues. I've found it quick and easy.

[Tom Sightings]

I had HIP/Emblem Health insurance for over ten years, and I thought they were very good. In all that time they disallowed one procedure; and about 15 minutes on the phone cleared it up.

The only problem? My premium kept increasing, year after year, sometimes as much as 15 - 20%. But I'm about the only person I know who doesn't blame the insurance companies. I blame the medical establishment that charges ridiculous prices ... I remember the $900+ charge for an ambulance to take my son 3 miles to the hospital emergency room when he cut his head in college; I remember the $500 charge for an X-ray of my hand ordered by a physician's assistant because he wasn't sure what he was doing. And I'm sure you have plenty of other examples.

I also think of my friend who had to get a pacemaker installed in his chest. The total medical bill was about $140K. His insurance company (not the same as mine) paid $135K. He had to pay $5,000, and he was bitching about it. But I think he got a pretty good deal ... at least from the insurance company, if not from the doctor and hospital.

[Retired Syd]

Tom:

I might have to blame them both equally. The cost of delivering medical care is outrageous, and worse, it varies from hospital to hospital, area to area. Besides that, you can't easily find out ahead of time what something will cost you--imagine any other business operating that way: Come stay at our hotel and at the end of it we'll tell you how much it was. Or fly this airline, and after you land, we'll tell you how much that's going to set you back. It's insane.

But clearly we have a problem on both ends if the hospital and my insurance company (and of course I) have to spend so much time sorting out this ridiculous $19 charge. I had to sort out one in the past with another insurer for $30,000 (in the end my portion was ZERO), but I think the whole system would be a lot more efficient if the patient didn't have to spend hours on the phone working all of this out. (And if the doctors' billing departments didn't' have to spend so much fighting the insurance companies, etc. etc.)

And don't even get me started on the drug companies! In any case, it's not a very efficient system.

[suz]

Here is a person who does like her health insurance plan. I have developed a chronic disease that my insurance has covered without question for multiple surgeries and medications. I work very hard at my job and do pay for a part of my healthcare to have this insurance. I am grateful my company has such great insurance available for the employees.
I enjoyed this blog when it was about retirement-but now it seems like you wish to take on healthcare (and everything that you think is wrong with it) as a cause. I appreciate that you can do what you wish with your blog, but I will unsubscribe since is no longer relevant to me or enjoyable to read. Thanks!

[Cindi]

The most expensive thing in retirement IS health care. Duh? As to the person who likes the insurance she is getting through her job, that'll change in 2016 January.

Anyway, Syd, I've given up on health care. Yes, DH and I have a policy but I don't think we'll be using it. First off, when I checked in December if our doctors will be on our new plan, they were. But come January 1st and beyond, when we made appointments for office visits or check ups almost all of them told us they opted out of our new ACA coverage. We're in no hurry to find new doctors, such as cardiac, infectious disease and even a gyn for me. We're still paying off our deductibles from last year. DH, despite reaching his $1200 deductible, still has over $3000 to pay off. How does that happen when you've already reached your deductible? Easy. For example, one procedure, after reaching his deductible, cost $1500. The insurance co said the value is only $500, so that's all they paid. DH is responsible for the $1000 left over. That's how.
If DH or I do get sick, we'll go to a walk-in clinic and just pay the bill. In the long run, it's cheaper than using the new insurance we have now.
As for a flu shot, I got one once and was sick for 3 weeks afterwards. I wound up with pneumonia. Never again. Instead, this winter, I have discovered the 'Hot Toddy'. A shot of whiskey, 2 teaspoons of honey, a squeeze of a lemon slice, top with 1/4 cup of boiling hot water and stir. A few of those per night makes me feel fit, quite young and rather chipper. Haven't gotten ill at all this winter. Despite several bouts with the Polar Vortex.

[Retired Syd]

Cindi: Well that Hot Toddy sounds like my kind of cure!

Suz: Well I'm sorry to hear that. When I retired the question I heard the most frequently was, "What will you do about health insurance until you can qualify for Medicare." Believe me, healthcare definitely is a big retirement consideration for many people. As Cindi mentions, it is one of the biggest expenses in retirement.

[Rich Berger]

Apparently, quite a few did. Unfortunately, Obama consistently lied to them until he was safely reelected.

[Larry Fitzgerald]

Try an HMO-type carrier like Kaiser and you might have better luck.
If insurance companies did not push back, then hospitals and MDs would order up every exaggerated diagnosis, treatment, drug, etc. possible to make $$$. The issues you discuss in your post are only partially the fault of the insurance industry.
It seems that at least 30% of all HC patient visits and treatments are totally unnecessary anyway.
The US has too many specialists and too few family medicine MDs and nurse practitioners to keep costs down.
The fact that you and hubby waited until 2014 to get your first flu shots (I've been getting them since the 1970s) just illustrates that you planned to use the insurance industry to backstop any costs associated with contracting influenza. If you had faced the prospect of paying part or the full cost of receiving treatment for the flu, then your preventive decision-making would have changed. Those big Covered CA deductibles are going to make some people more accountable re:poor personal health behaviors. Pay the $19 and worry about something more important.
The "affordable" part of the AHCA appears something that now shocks people, when it was an issue in great question before this legislation was passed.
Obamacare believers like yourself have little credibility in complaining at this point or playing the endless blame game.
Sadly, Obamacare is just another factor making early retirement (the stated topic of your blog) more problematic for most people. Was that the point of your post?

[Retired Syd]

Larry: I agree, it probably isn't worth the increase in blood pressure to worry about 19 bucks--that was part of the point. A little bit of making fun of myself.

But my post wasn't really intended to support or criticize the ACA. (And do you really think I avoided a flu shot in the past because I didn't want to pay for it? Well then I'm really going to live it up with a free colonoscopy this year!)

It was just a little story--one that you and Suz didn't really enjoy--I can see that.

[suz]

Thanks Cindi, I understand about healthcare and retirement although that really wasn't the topic of this particular post. And a hot toddy won't cure what I have.
Fortunately I have a younger husband so if I retire early I can be on his equally good policy until he retires.
Syd, I am just tired of endless griping about healthcare. I get that it is part of retiring early but so are a lot of other topics, which I felt I got more out of. Thanks!

[Larry Fitzgerald]

To follow-up.......
Your statement:
"Unlike my old individual high-deductible policy, my brand new ACA-conforming policy now covers flu shots 100%. BUT ONLY IF YOU CALL THE INSURANCE COMPANY AND WAIT ON HOLD FOR AN HOUR AND FIFTEEN MINUTES. And even then, you still have to jump through a few more hoops."

Welcome to the new AHCA wonderful bureaucracy. Looks like THE REALITY is a little different that you were boasting about a few months ago. Not so simple getting something "for free" is it?

Next:
"Last month, Doug and I went to get our first-ever flu shots. By the way, we chose our health plan specifically because it was the only insurer whose network covered our wonderful, local medical facility."

Really....you are a 50+ yo couple and you are getting the first-ever flu shots. Totally amazing given the breadth of your background, knowledge, and worldly experience. Then, as you might be aware of, a big issue with the AHCA are the limitations of facility access for each plan.

Next:
" I’m being billed $19 for something that should be covered by my $879 monthly premium?"

What? Even with the more expensive AHCA plans there are substantial out-of-pocket costs to be expected. It's right there on the web sites for CC with specific estimates a person or family might expect to pay per month in addition to their monthly premium. You and your husband can surely expect to pay lots for a few prescriptions and office visits. Makes you think twice about a casual bike ride or ski day, doesn't it! As someone who has gone thru my 50s, you can anticipate paying many $thousands/yr above your premiums even if you are in good-excellent health. Stuff happens you know....

My guess is that the AHCA makes things better for about 30% and more costly for 70%. We'll see in the Nov 2014 elections, I suppose.

[Retired Syd]

Larry: Honestly, I'm not sure why you are so concerned about my past flu shots, or the absence of them. In my adult life, I've never had the flu. This year, the flu was expected to hit even healthy people in my age group pretty hard. So I got the shot. What does that have to do with being worldly? There are many people that don't get flu shots. You don't work for the flu vaccine company, do you?

Now onto insurance--this is not my first rodeo. I have had three separate surgeries to remove uterine fibroid tumors over the past 15 years (two failed and one successful). Each of those surgeries was with a different insurance plan. And two of the three of them resulted in hours and hours over months and months on the phone with my insurer to get all that was supposed to be paid for covered. Even though they were pre-certified. And I eventually worked it all out. And that was long before Obamacare. Have you seriously never heard anyone discuss problems with insurance carriers before Obamacare?

The good news is it's no worse than it used to be. The bad news is it's no better than it used to be. (Although now people that couldn't get insurance before are able to). You are still dealing with insurance companies just like you were before. They are a business and they need to pay the bills, make a profit, and pay shareholders.

I am absolutely sure that in the next 4 decades I will be dealing with some health issue or another--I already know it will run me thousands of dollars, but not millions. That's why I have insurance. Whether it's a bike ride, a ski day or cancer or a heart attack. They are all possible. Eventually something is going to get you. Are you concerned I don't know this? Why do you think I have insurance?

[Diane @anewchapter-diane.blogspot.com]

I love that you went to bat for $19. Sometimes it's just the principle that gets you going, and you have no choice but to fight. This is a crazy example of people doing their jobs without thinking, and it's the consumer who has to waste time correcting the problem.

[Retired Syd]

Diane: I'm always teasing my mother-in-law for going to so much trouble for little insignificant charges. Now I understand, once you sink your teeth in, it's hard to let go!

[Retired Syd]

Suz: There are plenty of people that have gotten bored with my writing after awhile--you are not alone. Frankly after six years of writing about the same thing, I'm surprised anyone is still hanging around! I appreciate your taking the time to let me know, but it's totally unnecessary, I don't take roll.

[Rick]

Hi Syd.

What? You aren't taking roll? Well, I was going to respond just to check in :-)

Have an awesome week!

[Retired Syd]

Rick: No, but you can still get extra credit for being nice. Gold star for you.

[Diane]

Oh Syd, what a great post! Since I've been married, I have Kaiser through my husband's employer. We pay no monthly premiums and have no deductible. Our doctor and pharmacy co-pays are tiny and there is no co-pay for lab work. OTOH, it's Kaiser, and a new world unto itself. I joke with my husband that I maried him for the health benefits and he retorts that he married me for the ... nevermind.

Another thing: did you notice that the brand of lollipop the bank provided is "Dum-Dum"? Makes me laugh and wince every time I see the little flowerpots full of 'em. Yup, the stagecoach bank. Oh, and I notice that they listen a lot better and ma'am a lot more once they've looked at my balance. Just sayin';-).

Finally, when you're done with the medical profession, would you mind taking on the cable companies? What a complete and utter scam! Why are they allowed to get away with the crap they pull?

Thanks, Syd. I've missed your voice the last few weeks.

[Retired Syd]

Diane: Oh the never mind, cute.

Wow, you're good they were Dum-Dums! Well my husband has the cable company wrapped around his little finger--so no complaints there. Maybe you need to hire him to call your cable company. He's never afraid to ask for a deal.

[Kathy Bee]

I enjoy your posts about health insurance because I'm in the same boat and it's just good to know that I'm not in it alone, and that someone is giving a voice to it. I just went through a nightmare signing up with Anthem Blue Cross after Aetna left the individual market in California and dumped me. I easily spent 20 hours on hold with them. Finally my Congressman called someone and got me some attention and it was straightened out. Health insurance is a big issue for a lot of people. Look how much we all pay for it every month!!! Even with employer contributions. Why would we ever complacently accept bad behavior on the part of insurance companies - if we do, it will only get worse.

And, I agree with the topic suggestion of going after the Cable Companies too.

Thanks - enjoy your writing.

[dgpcolorado]

Off topic, but with regard to cable: I decided decades ago when "pay TV" was introduced that I would never participate. So I have always gone with free over-the-air (OTA) broadcasts (and, until a few years ago, a VCR to time-shift programs).

Even out here in the boondocks there are several repeaters that broadcast to remote mountain residents. When the switch from analog to digital broadcasts was made I figured that would be the end but, to my surprise, the digital signals are easier to pull in. (And my PBS signal is in HD and gorgeous; I was so happy I sent them an extra donation!) So, for the cost of a simple TV antenna in a tree and a signal amplifier I still get free TV. I have a DVR hooked up to it so I don't have to worry about schedules and the like. (By the way, simple DVRs without subscription fees, such as Tivo charges, are available.)

Unless one is really into ESPN or some such thing, I suggest dumping the cable/satellite and going with OTA. Perhaps if you use the cable for internet and can get a bundle deal it might be worth it. Otherwise free TV still exists in most places and the cost of Netflix, and similar internet services, is pretty minimal compared to cable bills.

FWIW. For a thrifty early retiree, cable/satellite is not a necessity IMHO.