This is the punchline of the decision from NYSOH (one wonders who it is returned to, since the decision itself came from NYSOH) regarding my vast overpayment of premiums since February 1, 2017:
Meantime, in an effort to get a second opinion on treatment for my kidney disease that does not involve an every other month three day infusion of intravenous steroids during a six month immunosuppressive regime, I found an internist who is also a nutritionist and holistic practitioner. To get insurance payment for a second opinion from this out-of-network doctor requires prior authorization from the insurance company’s Medical Management Office, the outfit that determines if medical necessity justifies payment to an out-of-network doctor. The doctor’s office must call to get this prior authorization. I passed this information on to the doctor’s office and they told me they’d call to get the prior authorization.
Got a call back a short time later from Mary Rose, the office manager. She was told by the Medical Management Office that my insurance policy does not cover out-of-network medical services under any circumstances. I called the insurance company and was assured, again, that in a case of medical necessity, my insurance would cover the cost, or some unknowable part of the cost, of seeing an out-of-network doctor. The doctor just has to call to get prior authorization. I described what the doctor’s office was told: that I am not eligible for out-of-network coverage. “That’s because they didn’t get prior authorization,” Jasmine told me unhelpfully.
I am an attorney. I am somewhat articulate. I have long experience in not having strokes, even under brutal and gratuitous pressure. I described the freedom of insurance companies to commit fraud in a scheme where there is no meaningful government oversight of their activities. Citizens are mandated to buy private insurance, and are instructed to pursue all grievances about denied services with that private corporation that has denied them service. It is a perfect cul du sac. Services can be legally denied for a variety of reasons under the law: an incorrect NPI number or a transposed CPT code or any other legitimate business reason. I went on for some time about the lack of remedy for screwed insurance consumers and how tempted I was to put this case in front of a Supreme Court judge under NY State’s Article 78.
Jasmine was very decent about the whole thing. She told me she’d be extremely frustrated too, in my position. That human admission was rare, and no small thing. She spoke to yet another supervisor, a third, called me back and spoke to Mary Rose at the holistic doctor’s office. She walked Mary Rose through exactly what she needed to say to make my case that this second opinion was a matter of medical necessity for the Medical Management Office. It was good of her. In the end we wished each other a very nice day.
It almost made me forget that my fourth attempt to get an appointment to see the nephrologist highly recommended by Sekhnet’s long-time doctor failed today. Jinza the office manager still had to speak to the doctor I’d lost confidence in, and to that doctor’s supervisor, the one I’d been urged to see, before she could allow me to make an appointment. This has only been going on for two weeks, and it is a mere ten days since my former nephrologist emailed to say she’d instructed the front desk to make an appointment for me with her colleague, so why am I being such an angry fucking pussy about it? That’s the $64,000 question, doc.