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January 23, 2006
Desperate Working Parent Seeks Insurance Help Desperately
Susan, played by Teri Hatcher on the ABC hit series Desperate Housewives, has a wandering spleen, which requires immediate surgery. But from the trailer promoting next week’s episode, it looks like Susan—who is a neurotic freelance children’s book illustrator—doesn’t have health insurance. Reduced to desperate measures, I have a hunch Susan is going to try and marry a man who has health insurance in the coming weeks.
Susan’s plight rings familiar—almost 46 million Americans don’t have health insurance.
I have health insurance, and I’m desperate, too.
To understand why, you first need a little background: My son Leo was born on Halloween 2004 with a giant birthmark covering 80% of his back. The mole, known as a nevus, is big and ugly, but it can also be cancerous. Thus, it has to be removed. In the past year, Leo has had three surgeries to remove the mole.
And here’s where the desperation comes in. Aside from the angst, the insomnia, the eye tick, and the weekly doctor’s appointments, there's the sticker shock: Leo’s surgeries have totaled more than $100,000 so far—and my husband and I have paid, with the help of my parents and credit cards—our fair share of that. The ordeal isn't over, either. Leo still has at least two more surgeries to go. When it comes to dealing with UnitedHealthcare, our insurance company, I’m at my wit’s end.
Being a savvy personal finance reporter as well as a working parent with little time to burn, I figured at the start of Leo’s medical madness that I could fight the system and win. I planned to chronicle my experiences and write a story for the masses called: “How to Fight Your Insurance Company and Win.”
But before you can fight the system and win, you need to get organized. Here’s my organizational check list:
1) Keep a list of every important number (doctor’s offices, insurance claims, human resources, etc. with the names of contact people at each place) near the phone and by your computer.
2) Keep a notebook by the phone to log in every phone call you make relating to your insurance. Write down who you spoke to, as well as the time and date of the call and what was said.
3) Bookmark your insurance company’s website (most claims can be found on online). Visit the site frequently to monitor claims status—much faster than waiting for statements to arrive in the U.S. mail.
4) Keep a folder with insurance claims (filed by date) near the phone for easy reference.
5) If you work for a large company, find out if there is a team of nurses assigned to your company’s account. United has three nurses who monitor McGraw-Hill employees, and while they don’t work in the claims department, these nurses can be invaluable in getting things accomplished. (A shout out to Tina Hagar at United who has been wonderful to work with in the past few months!)
6) Some large companies offer patient advocate services as an employee benefit. That means your employer pays for someone else to deal with all the insurance legwork, so you don’t have to, which means you can actually come to work to do your job. I’ll highlight some companies that offer this benefit in the coming weeks.
In addition, you can hire your own patient advocate. See “Your Guide to the Medical Maze.”
7) Don’t give up. Last week, the head of human resources at one of the nation’s largest financial services companies told me insurance companies expect us to “Give up and go away.”
They don’t know who they are dealing with.
By my count, I’ve logged at least 70 hours trying to get Leo’s surgeries covered by insurance, most of it on my company’s dime because insurance people only seem to be available between the hours of 9 and 5. I’ve learned plenty from my mistakes, too. In the coming weeks I plan to share my tips on navigating the system with you in depth.
I’m on a crusade to improve the insurance system, and I invite you to join me in making difference. Because we want this blog to be educational and interactive, please share your experience about health insurance—the good, the bad and the ugly.
Benefits, Finances, Health
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I was extremely captivated with your entry regarding your son Leo's surgeries and your family’s dealings with UNH. I hope everything works out fine with your son.
Your experience, unfortunately, points to an ugly, underbelly of US Healthcare. As a person who works in healthcare and sees most sides of the system - payors, consumers and patients, I am not shocked to hear your story, just saddened.
There is a fundamental breakdown between providers and payors in this country. This includes how providers submit claims to payors and how payors pay (or don’t) claims. More times than not the consumer is left holding the bad. However, the provider likely didn’t get payed either, a key economic breakdown across the 1.7 trillion dollar system. You mention how you spoke with an industry insider that claims health plans simply will ignore you - he is correct. There is zero incentive for them to do otherwise. Regarding doctors, they face the same challenge; there are over 800 different healthcare insurers in this country, all of whom have with different criteria on how they want to receive patient claims – blue paper with pockadots or please put whether patient X is on birth control on like 56C and what brand.
These protocols change almost weekly. So as you and your husband are trying to stay up-to-date on Leo’s procedures, co-pays etc, the doctors/hospitals are poking their eyes out as well. Now, to get an even better vantage point of the crisis, 75% of healthcare in the US is administered via small doctor practices of 1-3 docs, not to mention large hospitals that perform the large, costly procedures. The divide between hospitals and payors is widening and consumers are stuck in the middle. I will say you are working at the right magazine; BusinessWeek has done an absolutely fantastic job in the past year covering the issues surrounding these massive problems – “The Digital Hospital” cover in March. “Hunting for Hospitals that Measure Up” in June and the feature on David Brailer, the president’s point man on digitizing all elements of healthcare (talk about a guy that will need a beer!)
With the president giving his state of the union next Tuesday and anticipation that he will set his 2006 healthcare agenda that will consist of the new “ownership” model, one has to ask, who is out there (company) that will actually make this happen? Who will empower consumers like you and your husband? Who will help doctors get out of the financial mess insurers put them in? I applaud you for tackling this issue. Will it change UNH or Wellpoint or Aetna …who knows, probably not. But it’s a good fight and one that needs to happen. The battle to change US healthcare will be won and lost in the doctor’s office…the point of care, where patient meets doctor. All the rest is where things get grey.
Posted by: John at January 25, 2006 04:38 PM
Thanks so much for the feedback, John.
The BW stories John refers to here are:
The Digital Hospital:
Hunting for Hospitals that Measure Up:
Posted by: Lauren at January 26, 2006 09:01 AM
Let me start by saying, I hate the health care industry. I identify with the frustration over the hours logged trying to straighten out insurance issues. I have suffered through many billing issues with United Medical Resources and UnitedHealth Care. Most of my problems were related to infertility treatment which is largely not covered by insurance. It was a fight to get any small portion of the tens of thousands of dollars covered.
My biggest gripe with the health care industry is they claim they want consumers to have more skin in the game (pay more money for their coverage) so they will make wiser and more cost effective health care choices, but there is no information available to make those choices with. For example, it should be possible to get answer to the question, “How much does it cost to have a baby?” I understand there are many variables to this but I wanted to assume a "normal” birth, at a specific hospital (Chandler Regional), with a specific health care plan. After many frustrating hours of phone calls I found that no one was willing or able to answer this question, not the hospital and not my insurance provider (UMR). What an up surd situation. Can you image if you went to by a car and were told just take it home and we'll tell you how much it is later? Then, when the bill comes you have to pay that amount? Just try to plan for your FSA!
One invaluable tip I do have to offer is: conference calls. One sympathetic person at UnitedHealth Care suggested a conference call between them, me, and my doctor one day. It took two tries to get all three parties on the phone, but the end result was the eventual resolution to a problem of contract rates. It was finally determined that my doctor did not participate in the contract rates that UnitedHealth Care was insisting they did. Once this was determined the correct amounts I paid were credited to my “out of pocket maximum”. Prior to the conference call I had spent hours going back and forth on the phone between the two getting nowhere.
I could offer several other maddening tales, but just thinking about them is raising my blood pressure. It is time that I do some productive work, so I will leave it at this.
Posted by: J at January 26, 2006 03:48 PM
Thanks for taking the initiative to do this, Lauren. Our daughter Megan was born almost 10 years ago with the same birthmark condition as your son Leo. We have had our ups and downs with several different insurance companies over the years. I can attest to the fact that tenacity pays off. Megan has had medical expenses which, although initially turned down, have been ultimately paid. One thing I would add to your checklist is to get your medical team together. In the case of our birthmark kids, there are some top-of-the-foodchain doctors who know much more than the "specialist" down the street. Most are quite approachable. Get them on your side, get them writing letters, and use their published articles from major medical journals to argue your points. This has always gotten our insurers' attention. Do your homework. THEN don't give up :)
Posted by: Mark Beckwith at March 6, 2006 04:11 PM
Unfortunately, the exact same problems exist in the entire insurance industry. I've seen the, "they're hoping we give up" strategies in home owners insurance when dealing with disaster survivors, I've personally be involved with auto claims and have been treated the sam way, and I have a relative that helps arrange funerals who has seen it with life insurance claims.
It's sickening that this problem doesn't have better coverage. I think it's one of the biggest problems the average consumer faces, that will require an absolute uprising of insurance holders everywhere (basically everyone) to fix.
Posted by: Lila at March 19, 2006 12:37 PM
You are absolutely right in that the insurance companies want consumers to just give up & go away. I was a medical biller and spoke to many patients who had no idea how to navigate the health insurance maze. I then started my own company: D&L Health Claim Solutions, LLC. We reduce your anxiety when dealing with your medical bills. We'll make your calls,verify the accuracy of your medical bills and advocate for you.
Posted by: Denise at August 15, 2006 08:43 PM