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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 24 of 24. This is the beginning of the thread.
Posted by fallsfall on August 30, 2003, at 13:38:00
My company is changing health insurance companies on September 1. My company alway buys top of the line coverage.
I was thrilled to see my new therapist's name in the book. But when I told him who the new company was he said that he was not a provider for them (and then said something about a lawsuit that he had with them). Not encouraging.
A couple of weeks ago I called the new company to find out what their "Usual and Customary" fee was for therapy. When I read the literature it looked like they would pay 80% of anything up to their Usual and Customary fee (and if my therapist charges more, which he does, then I pay the difference). Insurance companies don't like to tell you what their Usual and Customary fees are - they tell you to submit a bill and find out that way (but that seems a little late to me - you've already incurred the charge or 6 weeks of charges before you get their answer). So being the pushy lady I am, I ended up talking to a supervisor for the Doctor's phone service line (they don't talk to patients...). She gave me a hard time for a while but then looked at the details of my policy and told me that there were no Usual and Customary charges for my policy - that the company would pay 80% of whatever my doctor charged. I asked her 3 ways to make sure I understood it right. This was too good to be true.
I told my doctor that my paperwork said that (for biological illnesses, i.e. Depression) there was no limit on the number of sessions. He didn't believe it, so I called to confirm. I was told that there was no limit as long as they were "medically necessary". They couldn't tell me how they determined this, but did say that I didn't have to pre-certify. So if I don't precertify, and there's no limit, how do they determine this?
But this time I was told that for my Out of Network therapist to submit a bill that he would have to have a "contract" with the insurance company. I asked if they could send me a copy of the contract - No. I asked if they could send him a copy of the contract - no. HE would have to personally pick up the phone to ask for this. He hates this company. He's not going to sign a contract, and he certainly isn't going to call them. So it looks like they will not pay 80% - they will pay 0. And that would mean that I would need to change therapists. (I just CHANGED therapists).
So I called a third time. This time I was told that I could submit a bill from him and the insurance company would pay 80% and he didn't have to have a contract.
Just tell me what is true!!!
So this morning I started trying to figure out what I would do if I really do have to change therapists. I just went through a therapist search, so I actually have 2 other candidates. They are both listed in the provider directory (but so is my current therapist...). So I went online to find out if they were currently registered with this company. Reading the instructions on my card and on the site in (what I thought were) reasonable ways, I found 3 different lists of providers. Unfortunately, these two therapists weren't on ANY of the lists (but my old therapist was, so I know I was searching the right way). This does not bode well.
Of course, since it is Saturday there is noone to answer the phone. But you don't know that until you have pressed "2", "1", "4", "6".
I am so frustrated that this is so hard. I am finding it impossible to do anything except search through the web site hoping I can find a morsel of information that will put my mind at ease.
Any ideas on how I can put this on a back burner until Tuesday? I'm terrified that I'll be without therapy. So I feel like I have to DO something to resolve the problem. But there isn't anything I can do!!!
ARGH.
Posted by Tabitha on August 30, 2003, at 14:17:52
In reply to Insurance Obsession, posted by fallsfall on August 30, 2003, at 13:38:00
that sounds maddening. You will probably just have to submit bills and see what happens. And you may not even get consistent results then. At least it sounds like there's a possibility they'll pay 80%. Perhaps you should start getting the names of the reps to talk with, and write down what they say.
I have one tip-- if they refuse claims and you can't get any resolution, you can get your employer's HR person involved (the person they sold the policy to). Of course it's embarassing to do that, but I've found it to be necessary for some places that do the out-of-network provider runaraound.
Actually, if you're comfortable doing it, it might not be a bad idea to get your employer involved already, to get clarification on the out-of-network coverage. Or just to let them know what lousy service you've gotten from the ins company already.
Now, try to put it out of your mind for the rest of the weekend. There's nothing you can do yet.
Posted by temmie on August 30, 2003, at 14:31:34
In reply to Insurance Obsession, posted by fallsfall on August 30, 2003, at 13:38:00
Oh dear, I don't know what to advise. You've done exhaustive research .... It's terrible the way the health-care industry makes getting good quality health care such a guessing game. It's so unfair, and so inappropriate. I don't think you're going to be without a therapist/therpay -- but how to hang on until Tuesday?
Go for a walk ... call a friend ... go to bed with a video ... with a book ... or with a giving companion (!) .... Hang out with us online. Go to the movies .... The usual, you know -- light a candle, take a bubblebath ... write a letter ... call a friend? Go for a walk ... curl up with a good book, etc.
I'm out of ideas!
For me -- this chat board has been my mainstay. I've had three different therapists since my coverage changed in October -- and I've seen them each only one or two times, and spread out over almost a year! It's a joke.
Thank God for this place. Thank God for you and the many dear souls who have followed my ups and downs and responded with such interested, relevant suggestions!
Sending love.
Me? I'm going to pop a Xanax, head to the video store, spend as much time as possible in bed, and get up and get the start of my school year organized, files made, desk labels, etc. .... Just as soon as tomorrow dawns.
Again, sending love.
Temmie
Posted by Dinah on August 30, 2003, at 17:00:16
In reply to Insurance Obsession, posted by fallsfall on August 30, 2003, at 13:38:00
Oh Fallsfall, I'm so sorry. Not that we're sure yet that sorry is in order. But I know how hard you worked to find this therapist. And you really feel like he's what you need right now.
Since there's nothing you can do about it until Tuesday, I guess it's time for distraction and self soothing. Do I hear ice cream?
But I always like to obsess something into the ground. It helps me somehow. If that sounds more helpful to you, I'd be glad to help listen.
Posted by fallsfall on August 30, 2003, at 17:06:43
In reply to Re: Insurance Obsession, posted by Tabitha on August 30, 2003, at 14:17:52
Thanks. I sent the HR person an email on Friday.
I'm trying, I'm trying!
Posted by fallsfall on August 30, 2003, at 17:10:06
In reply to Re: Insurance Obsession (((Fallsfall))), posted by temmie on August 30, 2003, at 14:31:34
Thanks, Temmie.
I invited a friend to come watch a video. I wanted either "Bridges of Madison County" or "American Graffitii", because I know she hasn't seen them and I'll happily see them again. It wasn't until the 3rd video store that I found either one (American Graffitii). That wasted some time.
Now I need to clean the family room floor and wash some fruit for us to snack on, and clean the kitchen if I have time. But what am I doing? Typing here!!!! I'm hopeless.
Posted by fallsfall on August 30, 2003, at 22:08:48
In reply to Re: Insurance Obsession » fallsfall, posted by Dinah on August 30, 2003, at 17:00:16
Actually, I didn't have any ice cream today. Maybe that's my problem.
Thank you for the offer to be an obsessing buddy. My current plan is to try the distraction thing, but if that doesn't work you'll be hearing from me.
Posted by Phil on September 4, 2003, at 7:09:13
In reply to Re: Insurance Obsession » Dinah, posted by fallsfall on August 30, 2003, at 22:08:48
fallsfall,
I work for the state and, of course, Texas had a 10 billion dollar defecit this year so, even though they currently pay for a single persons coverage, the butchered our plan.
We have a $50.00 copay on meds, per family member.
You have to buy 90 days supply at a time mail order and our copays all went up. When they had meetings to explain the lack of coverage, people walked out when a drug rep talked.
I had to see my pdoc for an hour recently because of a little slippage in my grip. $175.00 per hour. BCBS 'customary is $60.00 an hour; they reimburse you 60% of that. 40 or so for 175.00 appt.
When I spoke to them, it took 8, VIII, eight people before I could get a straight answer as to why I had 4 claims unpaid. I didn't have a referral from my primary care doc. Cut to the chase, I see out of network doc and it is self-referred, I never needed a referral. I usually try to avoid docs they list because 1. they are usually new docs that don't know sh*t from shinola. 2. They aren't taking new patients.
I told BC that their customary fees were adequate in 1956!
Formulary: Formulary is a sham and shouldn't even exist, for instance..Lexapro and Celexa are non-formulary. They just tell your doc to switch the patient to Prozac, Paxil, Zoloft or one other..they don't understand. I sent them two emails asking basically why they were so f*ck-- stupid.
Oh, since buying 90 days of meds at a whack was a burden, the state introduced a bill, no sh*t, to charter buses to Mexico for employees wanting to buy meds there. This happened while the feds were lying that overseas meds weren't safe.
They settled on: You can buy month by month at your local pharmacy for about twice the mail order price.
I could go on but I could write 20 pages on these losers. One other thing: Hospital and ER used to be a flat $75.00 co-pay. Now they are $100.00 a day PLUS 20% of the bill.
The med companies and insurance companies are huge contributors to, especially, Republican pols. Med companies have risen to 11th from 17th in largest contributors to pols in one year. Drug prices are driving these increases.
I feel for you and all the rest of us because this is the future and it will get worse.
So, Texas was broke so they go with Merck-Medco(avoid at all cost, they suck). Merck is not a Texas based company. So, they screwed local pharmacies to send the money, billions, out of state.
And they wonder why we go nuts.
Good luck. I feel like I've fallen into a snake pit. I'm afraid, before this is over, med ins. will be as bad as dental-you don't want to hear our dental plan! : )
One more: I paid my doc $175.00 for 1 hour. I found out that $100.00 goes towards my $500.00 deductible going by the treatment code my doc used. GOTCHA.Thanks for listening.
Phil
Posted by fallsfall on September 4, 2003, at 7:49:37
In reply to Re: Insurance Obsession / Long... » fallsfall, posted by Phil on September 4, 2003, at 7:09:13
I just love it.
The fourth person I talked to read to me from my plan. I think my therapist is covered 80% of his fee. I'll submit a claim after I see him today and in 6 weeks we'll know!
Now my daughter needs new lenses for her glasses. We saw the doctor yesterday, and they think that they accept my insurance, but I can't find them listed anywhere, so they may be out of network for me. The place we usually get her glasses doesn't take it, so I've spent a couple of hours trying to figure out where to go.
Good thing I'm not working (I'm disabled) - I'd never have time for all this crap if I was.
Good luck, Phil!
Posted by Phil on September 4, 2003, at 8:55:39
In reply to Re: Insurance Obsession / Long... » Phil, posted by fallsfall on September 4, 2003, at 7:49:37
fallsfall,
Good luck to you too, fallsfall.
A short story: Several disabled people gathered on the Capitol steps earlier this year asking for help on various issues. They had to take it that far. Did Bush's protege score a PR coup by getting out of his office and tell them his plans to assist? NO!!!! He had them arrested.
Texas' motto at one time: "The Friendly State"
Maybe if you are a rich honky Republican.Sounds mean but it's true. I'm glad my anger is under control. haha
I like your posts.
Bye fer now,
P
Posted by Dr. Bob on September 4, 2003, at 10:14:36
In reply to Re: Insurance Obsession / Long... » fallsfall, posted by Phil on September 4, 2003, at 8:55:39
> Texas' motto at one time: "The Friendly State"
> Maybe if you are a rich honky Republican.You may not agree with them, but there may be Republicans here, so please don't post anything that could lead them to feel put down, thanks.
Bob
Posted by Phil on September 4, 2003, at 12:08:58
In reply to Re: please be civil » Phil, posted by Dr. Bob on September 4, 2003, at 10:14:36
Figured I had that coming. I'll try to mind my manners.
Posted by Dr. Bob on September 4, 2003, at 23:41:14
In reply to Re: please be civil » Dr. Bob, posted by Phil on September 4, 2003, at 12:08:58
Posted by chicklet on September 5, 2003, at 14:08:01
In reply to Re: Insurance Obsession / Long... » fallsfall, posted by Phil on September 4, 2003, at 8:55:39
I am very hurt by your slanderous comment. :D
Posted by Gabbix2 on September 5, 2003, at 16:08:31
In reply to I am a rich Republican and » Phil, posted by chicklet on September 5, 2003, at 14:08:01
a liar..
Do I get blocked for telling the truth?
Posted by chicklet on September 5, 2003, at 21:00:46
In reply to and you are also » chicklet, posted by Gabbix2 on September 5, 2003, at 16:08:31
But today i am still
just a bill.
Posted by KimberlyDi on September 9, 2003, at 11:03:44
In reply to Insurance Obsession, posted by fallsfall on August 30, 2003, at 13:38:00
I don't have to pre-certify my p-doc. But those visits are somehow included on my 30 session limitation per year to visit my therapist, which I *do* have to pre-certify. Learned that lesson the expensive way.
AND they are limiting my prescription coverage to 62 pills a co-pay. 3x100mg of Effexor? Nope. 2x150mg of Effexor XR? Sure thing! If my p-doc calls and argues with them. She called and argued about the Strattera too, but someone neglected to tell the pharmacy. $50 for 1/2 month supply. The Strattera was only 2x40mg (falls under the 62-pill limitation) but apparently my insurance wants to discourage treatment of adult ADHD.
ARGGGHHH!!!
Posted by KimberlyDi on September 9, 2003, at 11:15:30
In reply to Re: Insurance Obsession / Long... » fallsfall, posted by Phil on September 4, 2003, at 8:55:39
I'm a poor white Republican. :) honky is slang for white, right? are you non-white?
<grin>
KDi in Texas> fallsfall,
>
> Good luck to you too, fallsfall.
> A short story: Several disabled people gathered on the Capitol steps earlier this year asking for help on various issues. They had to take it that far. Did Bush's protege score a PR coup by getting out of his office and tell them his plans to assist? NO!!!! He had them arrested.
>
> Texas' motto at one time: "The Friendly State"
> Maybe if you are a rich honky Republican.
>
> Sounds mean but it's true. I'm glad my anger is under control. haha
>
> I like your posts.
>
> Bye fer now,
> P
Posted by KimberlyDi on September 9, 2003, at 11:16:53
In reply to I hope and I pray that you will » Gabbix2, posted by chicklet on September 5, 2003, at 21:00:46
Conjunction junction, what's you function?
But today i am still
> just a bill.
>
Posted by Dr. Bob on September 9, 2003, at 18:09:01
In reply to Re: Insurance Obsession / Long... » Phil, posted by KimberlyDi on September 9, 2003, at 11:15:30
> honky is slang for white, right?
Please don't use language that could offend others, thanks.
Bob
Posted by KimberlyDi on September 10, 2003, at 12:45:21
In reply to Re: please be civil » KimberlyDi, posted by Dr. Bob on September 9, 2003, at 18:09:01
Someone else used that word in his post
Posted by Dr. Bob on September 10, 2003, at 19:47:34
In reply to I just asked for clarification but ok. » Dr. Bob, posted by KimberlyDi on September 10, 2003, at 12:45:21
> Someone else used that word in his post
I know, but 2 wrongs don't make a right...
Bob
Posted by KimberlyDi on September 11, 2003, at 17:15:24
In reply to Re: thanks, posted by Dr. Bob on September 10, 2003, at 19:47:34
Posted by stjames on September 11, 2003, at 19:56:51
In reply to Insurance Obsession, posted by fallsfall on August 30, 2003, at 13:38:00
I've played the HMO payment game for decades.
The fight begins once the claim is filed but
you cannot fight them till the claim is filed
and rejected. many flat out reject a % of claims
just because they can, to keep profits and numbers up. However if you keep it up they will pay. One of these days. they expect to reject claims and have the % of their customers not contest, even if the claim is valid.
This is the end of the thread.
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