Note to Eric

As predictable as it is SAD!

Dear Eric:

Please excuse the liberty, colleague, I’m responding to the November 6 letter from one of your Division of Social Justice assistants, Jennifer Lonergan, who incorrectly stated that I had addressed my letter of October 12 to “Eric Schneiderman”.   

I voted for you in each of your State Senate elections and for A.G.  I share many of your political views, including the belief that a primary role of government is protecting citizens from the predations of the powerful.  I applaud the proactive stances you take on many important issues.  I don’t blame you personally for the inadequate response to my long and detailed letter, though it reflects poorly on the office that acts in your name.

Ms. Lonergan begins her point by point refutation of my painfully researched assertion that the New York State regulatory help scheme for low income health insurance consumers is a cul du sac by demonstrating active listening, the dismissiveness of her tone in restating the obvious probably inadvertent:

It appears that it is difficult for health care consumers, such as yourself, to ascertain where to turn for help regarding various health care issues, and further, that you received misinformation from various entities tasked with assisting consumers with health care issues.

Ms. Lonergan, although perhaps not fully grasping the blood pressure elevating vexation that unregulated health insurance causes low income New Yorkers,  did an impressive amount of cutting and pasting in assembling a letter full of potentially helpful sources that could possibly solve some pressing healthcare-related consumer problems within only a few months.  According to her, the help desk in your office is more than a match for most of the vexing, unregulated consumer abuses detailed in my letter.   

Her response to this paragraph was noteworthy:

Essential Plan members do not have a right to file complaint appeal (sic).  If they need assistance filing a grievance or appeal, they may also contact the state independent consumer assistance program at:  Community Health Advocates, 105 E. 22nd Street, NY NY 10010 or 888-614-5400 or email at cha@cssny.org

source:  Anthem’s National Contact Center Document under NY market tab for “Essential” plan updated as of 12-14-16 at 7:56 a.m.

She informed me, presumably based on research unavailable to a consumer like myself, that the health insurance representative had been mistaken when he pretended to read corporate policy from his customer service manual.  This leaves me marveling at the rep’s inventiveness and eidetic memory,  “reading” me the identical made up wording several times, so that I could transcribe it accurately.  Adding that it was printed in red, and providing an invented source, were truly brilliant, if diabolically misleading, touches.

Ms. Lonergan also corrected my slipshod use of the legal term “fraud”; she was good enough to point out that I had not established an essential element, since doctors I’d been referred to by the insurance company who had refused me treatment had not actually taken payment from me.  I guess, arguably, the premiums I pay every month to the corporation that referred me to these doctors are beside the point for purposes of a claim of fraud.

I greatly prefer the letter from Mr. Bockstein (attached), which, while clearly sent to me in error, at least spelled my name right and did not dismiss the health-threatening concerns I’d taken pains to detail carefully for your office’s consideration, practices I offered as illustrations of the desperate need for the policy changes I suggested.  I subsequently had Mr. Bockstein’s kind assurance that my original letter was under consideration by an advocate named Jennifer Lonergan who would be getting back to me.  No point beating a dead cul du sac here.

I suppose the most honest letter I could have received in reply to mine would also have been the most depressing: low income healthcare consumers get whatever care they get, and whatever version of due process goes along with it.  And though they may address a letter to a champion fighting institutional injustice, with the power to advocate changes to grossly inadequate protections under the law, they can expect, at best, a letter like Ms. Lonergan’s.

Have a great day,
Eliot “Widaeu”

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For reference, the corrected file number on my original letter is 1370738.  Presumably my letter is also preserved under that file number.

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This One I Truly Don’t Get, Obama

Happy Thanksgiving, first of all.

I had the usual holiday bot response from the New York State of Health Marketplace this morning at 8 a.m.   An important message in my inbox, the email advised me, which, of course, could be any message whatsoever.  Last Christmas, on the day, that important message told me, in error, that I would not be receiving the subsidy because my income, well within the range for the subsidy, well — no subsidy.   That only took five months to fix.  The year before I think it was New Year’s Day, I was informed that my health insurance was cancelled and could not be restored until March 1st, but only if I uploaded a series of demanded documents within seven days.   

The emails tell you to log on immediately to see the important message.  Presumably this is done for your privacy.  If they sent you an email saying: congratulations, your enrollment for 2018 is complete, see message in your inbox for details, anybody hacking into your email could see that you were eligible for insurance coverage in 2018.  It’s confidential, of course, and your confidentiality is very important to us, so please go to your inbox for this important message.

Your NYSOH inbox shows all these messages marked Template, with various random, inscrutable template numbers.   Even in your private inbox there is no indication of what these various messages may say, only the dates they were sent to you.   You must download these form letters, in PDF format, to read them.  OK, this is a witless bureaucracy and presumably they can save money by having a tireless, unpaid bot send you a generic email each time NYSOH communicates with you, and also, by putting Template 099 next to each message in your inbox, instead of labeling them; enrollment, immediate action required, seven day notice, health insurance in jeopardy, what have you.

Here is the part that truly confounds me.   It has nothing to do with Trump defunding Obamacare advertising, or Republican sabotage of a law they despise that happens to allow more low income people to have health insurance, or the current, most excellent president’s fanatical zeal to overturn everything his slippery, lying Kenyan-born secret Muslim predecessor managed to enact.  It has nothing to do with the flawed design of the cleverly named Patient Protection and Affordable Care Act.  It is just a puzzle, and I have no idea what is at work, outside of plain, simple human stupidity and bureaucratic rigidity.  I literally have no clue, outside of the usual shabby consideration given to people affected by any government program that serves those who are in any kind of financial need.

On October 24th I had an email from NYSOH, the only one I had since July.  In July the important notice, Template 077, told me what I already knew.  It turned out to be a condensed electronic version of the mediator’s decision that I had been entitled to a subsidy all along, and that it was restored, retroactive to the first premium payment of 2017.     Bear in mind that this October 24th notice, which I read the other day, was the only notice I will receive about deadlines for re-enrolling to be eligible for health insurance in 2018.   Page two (of ten — one blank, four related to registering to vote, in many languages) reads:   

 

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Dig this.  Not only are the IF categories forgetting one important IF– if you want health insurance for 2018 you will have a thirty day window to get it, but there is something far worse.  (OK, I have to admit, in fairness to these sloppy assholes, that page one informs me that “ACTION IS REQUIRED by December 15” so that an appropriate — or inappropriate– decision can be made on my health insurance coverage for 2018).  

Here’s the mystifying thing.  This October 24 form letter is the only notice you anyone on Obamacare will get regarding your health insurance for 2018.  On October 24 you get an important notice telling you that beginning on November 16 you will have thirty days during which to purchase your 2018 insurance plan.   Mark your calendar carefully, asshole.  Note: we changed the arbitrary deadline this year, it no longer extends to New Year’s eve.

Leave aside all the other institutional problems with a health plan that is based on private insurance companies selling you insurance.  Forget the rabid profit-crazed foxes left in charge of the henhouse.  Forget all of the gripes about the problems of the original PPACA, unaddressed by a Congress full of twitchy fundraisers, half of them fanatically focused on repeal of the popular law.

I live in New York State.  This state was one of the original adopters of the PPACA.  When it came into law the state abolished its own program for low income New Yorkers.   New York State was all-in from the beginning.   It’s not like the state is in the hands of people that have any motive to sabotage the law or deny anybody coverage.     That is the case in many states, who refused to participate fully because they opposed the conservative health insurance compromise on principle, because it was sponsored by a post-racial president.  (Post-racial, wink wink, you get what I’m sayin’?)

Does anyone have any idea what the logic, if any, of this single important notice given three weeks before the short holiday season window opens for buying the following year’s health insurance could be?  Outside of another random example of exceptional American human idiocy?

I suppose I could ask Donna Frescatore, the director of NYSOH, a political appointee who doesn’t allow reps at NYSOH to divulge her name (why should she?) — but that would seem churlish, don’t you think?

The World is Easy Enough — when you handle it right …

Mr. Bockstein was most pleasant during our less than ten minute conversation just now (most of it on hold, granted, while he looked under the file number on the letter he mistakenly sent me).   He soon told me to forget about that letter, it had been sent to me in error.

The initial wait to speak to him was less than 40 seconds, which is great.  The wait when he looked up his erroneous letter to me, after I explained I’d received it in error and read him the reference number he’d assigned, was less than five minutes, again, quite reasonable.  The letter under reference number 1369393, it turns out, was not responsive to my complaint.  OK, mistakes happen. 

“Obviously it was meant to go to somebody else,” I said when he confirmed that his letter about my complaint against two entities I’d never heard of had been sent to me by mistake, “my concern is that I wrote a long and very detailed policy-related letter to the Attorney General and I’m not sure why I was getting a response from your subdivision of his office.”   

“Do you remember what it was about?” he asked me.  “Because I’m not finding…” 

“My letter was, the cover letter was two pages and there were about twenty pages of attachments. I was proposing legislation to remedy some terrible  oversight problems with healthcare and the administration of the PPACA in New York State, and my letter…”   

“Hold on, hold on,” he said, still trying to make sense of why he couldn’t find any trace of my complaint in his system.  Then he confirmed the spelling of my name and asked me to hold.  This time he remained on the line as I waited.  He was breathing in an exasperated manner because his computer was apparently buggering him while I held.   He let out one long, loud, exasperated exhalation, then continued to breathe more or less normally as I waited for him to find my name.   He let out another exaggerated breath and said imploringly “come on, computer, will you please?”   It was nice to be speaking to a human being, I thought idly to myself.   

“OK,” I finally said, “so actually, my question is how can that letter be placed in the hands of an assistant that reads policy and proposed legislation-related letters for the A.G.?”   

“Well, that would have to go to… hang on a minute…. did you file a complaint?”   

“No, I never filed a complaint with your bureau.” 

“You didn’t file a complaint about Healthfirst and the Marketplace?” 

“No, the letter discussed Healthfirst, and the Marketplace, and a number of other things.  It also discussed Blue Cross/Blue Shield and some systemic problems… basically it was a description of the cul du sac of consumer help that anyone who has any problem with health insurance finds himself in in New York State and it was proposing several ways to…”   

Mr. Bockstein, whose computer had apparently just released its uninvited, amorous, two-handed grip on his waist interrupted to give me the good news.  “Your complaint was assigned to one of our advocates.  Her name is Jennifer Lonergan and she will be responding to you based on your complaint.  As for that other one,  just ignore it.” 

“Well, I mean, I can certainly ignore it,” I agreed, “but I, you know, I was hoping it was not the end of a letter I spent a lot of time writing.”   

“No, no-no, no, no,” assured Mr. Bockstein at once, “your complaint has been assigned to an advocate, it’s being reviewed and the advocate will respond to you.”   

I confirmed the spelling of the advocate’s name, he gave me my correct file number and I thanked him very much. 

“OK,” he said affably enough. 

My recording ends with a long exhalation by me, a moment after I pressed disconnect to end the call with Mr. Bockstein. 

 

 

No Reason to feel like a Chump, Chump

My bad, really, in not beginning that letter to the NYS Attorney General’s office with an unmissable disclaimer:  THIS IS NOT A BILLING COMPLAINT.

No wonder that a healthcare-related letter, complaining of the lack of any sort of government agency to resolve health insurance-related problems NYS patients have in New York State, would be dropped promptly on to the Healthcare billing dispute desk of the A.G.’s office.   My letter, foolishly, began:

Dear Mr. Attorney General:

I am appealing to you for assistance, on behalf of many thousands of New Yorkers caught in a sometimes life-threatening situation regarding their healthcare.  As described more fully below, citizens of our state have no government agency that intervenes in cases where patients are mistreated by the corporations we buy health insurance from.   This is true even in cases of apparent fraud.  

An idiotic idealism had me send it, for myself and on behalf of other people many Americans believe are lucky to have any health insurance at all– and who are in danger of losing the shit care they currently have.  I am not a campaign donor, or an Ivy League classmate of anyone close to the A.G., why would I expect my letter to reach such an important man?   If I was a wealthy, connected person, what would possess me to write such a letter in the first place?  Not being one, what did I fucking expect?   Perhaps anything but the mistaken response I received:

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But still.  And although the letter is non-responsive to anything in my letter, it is easily enough straightened out.  I could do it in couple of lines:

Dear Mr. Bockstein:

Thank you for your prompt reply to my long letter to the Attorney General, though it was clearly sent to me in error.   My correspondence did not involve a billing dispute (though one section contained examples of a couple), and I never heard of St. Joseph’s Physicians or Oneida Healthcare, let alone had a billing dispute with either of them.   Please transfer my letter, and the attachments, to the assistant for Mr. Schneiderman who reviews policy-related correspondence.  Or let me know to whom I should address a new copy, to avoid a similar fate to copy number two.

Thank you, and have a blessed day.

No need to point out the obvious irony to the overworked Mr. Bockstein — that his idiotic ‘response’ to my letter is yet another stunning example of the administrative cul du sac I described in my letter as so infuriating and soul crushing to aggrieved low income patients of New York who have no government agency protecting them from the predations of the health insurance companies they are mandated to purchase healthcare through.

Or that bureaucratic responses such as his are particularly dangerous to patients being treated for serious major organ disease and already suffering treatment-related extreme high blood pressure.   When your blood pressure is dangerously close to hypertensive crisis range, a letter like that, though polite, is the last fucking poison you need.  Although it is good for me to keep in mind that the preventable death of an American who is not at least middle class is, as the law styles it, a trifle, truly.  Nothing personal.

I rest my case, Mr. Bockstein.  I’d make an idle threat to rest it in a venomous letter to the editor of the Grey Skank, but we all know how silly that would be to threaten.  Theoretically, a tart letter to the editor quoting the AG’s response would momentarily embarrass your boss, who appears to be one of the few good guys, and who is tirelessly making a good name for himself with clear future ambitions.   On the other hand, a short description of the callous, or at best, inept, functioning of his progressive office would only serve to provide more ammunition to the powerful and well-funded forces of reaction bent on returning this country to its former greatness.

I am left idly threatening to unearth my Louisville slugger, Joe Pepitone model.  And fiercely pointing out that I can be up in Albany in the time it takes Mr. Bockstein to crank out a few dozen of these fine letters, man of peace and reason though I always aspire to be.  At the same time urging Mr. Bockstein, for purely legal reasons, not to construe this as any kind of physical threat– I mutter it mildly and abstractly, for expressive purposes only, through a haze of monoclonal antibody side effects.  Though, even in my asthenic state, I recognize that, truly, the many vexations of Americans with a low income, even the most theoretically easily preventable vexations, are strictly their own affair and attributable only to their poor choices in life.

You Can’t Make This Shit Up…

Which doesn’t mean, of course, it doesn’t make you want to smash the responsible parties in the face with a baseball bat, just once.   As a man who tries to practice Ahimsa, non-harm to fellow creatures, the feelings this can produce are complicated.

Many things are complicated, granted.  Our exceptional country, we can stipulate, has a sometimes spotty history for doing the right thing.  We know liberals are always banging on about the extermination of the native people, slavery, atomic bombs dropped on Japanese civilians after back-channel surrender talks were in the works, segregation,  a century of lynching, the “pre-emptive” invasion and destruction of Iraq, torture, drones, imprisonment of more than a million Americans for arbitrary crimes that harm nobody, a powerful, wealthy gun lobby that makes sure tens of thousands of Americans are free to kill tens of thousands of other Americans every year, blah blah blah– as if liberals never do anything wrong.   

Our world’s most expensive health care system, its expense inflated by fabulously paid private insurance middleman as much as by high tech medical interventions and Big Pharma, vital industries which are sometimes judgmentally called ‘predatory’, allows tens of thousands of Americans to die every year over money issues, even under Obamacare.   Oh, and intergenerational poverty and racism, and not paying women as much as men and not fixing that.  OK, we’re not perfect, but we’re always trying to form a more perfect union.   

Once in a while someone who thinks they’re smart tries, in the face of odds that say, overwhelmingly ‘shut the fuck up, anonymous, powerless asshole’, to write a cogent letter to someone in power who might be moved enough to address at least one systemic, institutional injustice.   I was one such person recently, and I exerted myself mightily over many months, to craft a letter that was readable and proposed solutions to the institutional problems it detailed.  I sent it to our activist, progressive,  not publicity-shy NYS Attorney General.   You can read the final version of my letter here, and the attachments to it here

To my relief, I got a prompt response, from the Attorney General’s Division of Social Justice, no less.  Here it is.  You truly can’t make this shit up.

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Of course, it would seem churlish of me to note that I’ve never heard of St. Joseph’s Physicians/Oneida Healthcare, nor, to my knowledge ever had a billing dispute with either one.   

Hopefully I can remain calm and relatively civil tomorrow when I call this steaming pile of distracted dung, Health Care Bureau Intake Specialist Alexander Bockstein, and inform him that my letter reached his desk in error, as his did mine.   I will need to strike just the right tone to get my letter into the hands of someone who will thank me for it in a manner a bit more on point, indicating they may even have read a paragraph or two of it.  You know what I’m saying?

You sound a bit… insane, sir

I am scheduled to have the first of two five hour infusions of a drug called Rituximab on Friday.  This drug is usually used for lymphoma patients, as far as I can tell, after a visit to the manufacturer’s website.  Nephrologists have recently found Rituximab is often helpful in curing the kidney disease I have, membranous nephropathy.  I am resigned to being hooked up to a slow dripping bag of this miracle drug, which seems to have a fraction of the side-effects of the steroid-based chemo regime I was being pressured into a few months back.   My current nephrologist recommended three vaccines before I start, as the Rituximab will suppress my immune system.  

I had a flu shot, and a pneumonia shot.  I’ve spent the last ten days or so trying to get the third — an immunization against shingles.  From everything I’ve heard, shingles is something to be avoided.    I am prone to skin troubles, I am over sixty, I have an auto-immune disease, had chicken pox:  I am a good candidate for this potential side effect of the immunosuppressive regime.  

My primary care doctor, for whatever bureaucratic reason, could not order the pneumonia and shingles vaccines.  He gave me a prescription to fill.  The pneumonia vaccine was easy to find, the shingles vaccine, not easy.  I have been to seven pharmacies so far.  My local pharmacy, for whatever reason, could not order the vaccine.  Two chain pharmacies had the vaccine, RiteAid ordered and quickly procured it, and DuaneReade had it in stock, but they do not accept my insurance.    

It costs about $300, if I wanted to plunk down my credit card.   Four pharmacies that accept my insurance, CVS branches, did not have the shingles vaccine. The CVS closest to my apartment has been waiting months for it to come in. The pharmacist at the last place, the one that had the vaccine, but doesn’t accept my health insurance, suggested I call Healthfirst, the corporate gatekeeper of my health care.

It was not a terrible suggestion, but past experience whispers now that I should not have made the call.   For one thing, the inviolable policies of corporations are not something mere mortals can question, let alone contest. For another, there is the psychological angle — I cannot separate the practices of one homicidal legally-created psychopath from those of another homicidal legally-created psychopath, and I hate them all.  

“Homicidal” sounds so judgmental, I know, but do the math.  I live in the USA, where tens of thousands die every year for lack of affordable access to adequate health care.  It’s a cost of doing business here in the Land of the Free and the Home of the Bankrupted by Cancer.  We don’t bat an eye about the annual preventable deaths, more than tenfold the death toll of September 11, 2001, every year.  We have reality TV, social media, a big American Dream, evil people to hate– so people die here, like the tens of thousands of Americans who died of oxycodone and heroin overdoses last year, what’s your point?  Your little problem?  Fuck you, asshole.  Get a better life, make enough money to buy whatever you want, including good health care, and shut the fuck up about ‘injustice’, boner breath.

In fairness, and we should always strive to be fair, insurance companies do not make money paying out claims, the profit is in paying out as little as possible.   In a nation that was not insane, stoned beyond reason on “free market” kool-aid, it would not be a patient’s problem to figure out how to get a needed inoculation paid for by the insurance company he pays a premium to every month.  

My trouble is that I can’t separate the frustration and the indignity from the injustice any more.  I get angry, though I control my language, and I cannot help but remind the helpless representative, reduced to meaningless apologies, that she works for a corporation, something we pretend is a “person”, but is the kind of person incapable of conscience, empathy or anything but naked self-interest.   This does not sit well with some of the reps.   They are not being paid enough to listen to this kind of shit from someone who is angry that he has to keep calling a murderous psychopath for help with healthcare.  Murderous psychopaths do not give a fuck, what kind of idiot does not know that?  What kind of moron tries to argue with representatives of an artificial “person” who is also, by definition, a murderous psychopath?

By the end of yesterday’s marathon 40 minute chat with an excessively polite woman named Ilene, the obstacles escalated considerably.  Not only, did she inform me, (after two long holds for consults on how to deal with an insane raging asshole, and a sickeningly articulate one), would Healthfirst not pay for a shingles vaccine administered in a pharmacy, assuming I could even find the drug anywhere, the shot must be given by your doctor, in his office, after he receives pre-authorization from Healthfirst.   

As for how long that pre-authorization might take, nobody has any idea. Could be fast, could be very slow.  Ilene, after all, is on the membership side of Healthfirst’s corporate brain.  Pre-authorizations come from the provider side.  These two sides have no way to communicate with each other.  I have experienced this before.  It was a kind of last straw yesterday.  I remarked that it was handy, for an artificial “person” without conscience,  to have a divided corporate brain that could not communicate between the halves in order to answer a simple question.  Before I could utter a stream of horrible curses nobody would be able to unhear, I thanked Ilene in an acid tone and wished her a good day.

The pharmacist in Sekhnetville, who has ordered the vaccine, assured me that they give shots to Healthcare customers all the time, that it should be no problem, once the vaccine comes in, to shoot me up right there.  In hindsight, I suspect that Ilene, being a polite and hardworking girl, probably from the mid-west, had found a way to tell an insane asshole to go fucking fuck himself, in the politest, most vicious possible terms.

The latest call to the pharmacist in Sekhnetville, who promised the vaccine would be in today, revealed that… oops, the manufacturer does not seem to be currently shipping the vaccine.   It appears to be on back order.  Could be weeks, or even months.  So, sorry.   Have a very nice day.  Unexplained is why RiteAid was able to procure the drug within a couple of days, or why the shot was available at DuaneReade.

Looks like I’d better reach for my credit card and just have the fucking shot at one of the “out-of-plan” pharmacies that currently have the shit.

USA! USA!!!!  Nice work, Barack, rocking that big, lucrative corporate boat as gently as possible while making some small, long-overdue improvements for more folks who couldn’t previously afford health care.  Good luck with your book sales and paid speaking tours, my man.

 

 

 

Attachments for the letter to the A.G.

Attachments to this letter.

#1  The NYS Health insurance Consumer helpline cul du sac

In an attempt to resolve problems with my health insurance I contacted a circuit of government agencies in vain last December.  Here is a summary of that healthcare consumer help cul du sac:

The NYS Department of Financial Services helpline (from dfs.ny.gov) referred me initially to the US Department of Health and Human Services (877-696-6775) which, supposedly, connected me to NYS Health and Human Services, although to an incorrect branch of that agency, the pertinent branch apparently having been merged into the NYS Department of Financial Services which took over all functions of the former NYS Insurance Department as well as oversight of banking and several other discrete and seemingly unrelated areas.  (When I called this number today, it gave me an option, unavailable last time, to press 6 for “consumer problems with the ACA”, and offered a call back in five business days from a representative.)

The New York State Insurance Department, along with other agencies related to healthcare in New York State, was merged into the Department of Financial Services when New York adopted the Patient Protection and Affordable Care Act (“PPACA”).  The New York State Department of Financial Services, it turns out, does not hear consumer fraud complaints against health insurance companies.

I entered this administrative cul du sac in December 2016 after Empire Blue Cross “Health Plus” sent me to two in-network providers for needed medical services, a cardiologist (for follow-up care after a hospitalization for cardiac issues) and a physical therapy facility.  Neither provided me with any service. 

The fraud investigator I eventually spoke to at the NYS Department of Financial Services, at the end of a long chain of calls, could not find a word other than ‘fraud’ to describe the facts I set forth, but urged me to call the NY State Department of Financial Services Consumer Services Hotline.  He assured me that they were the specialists in the area of health insurance.  The recorded menu at the hotline, which I recognized from my first call hours earlier, offers no option for resolving issues with insurance companies of any kind.  

On my original call to the Department of Financial Services, a long wait to speak to a representative yielded the number of the proper federal agency to contact.   Calls to the U.S Department of Health and Human Services are robotically routed to a NY State number that is, sadly, the office of Temporary and Disability Assistance, where a helpful party connects you to a fraud hotline, which turns out to be at the office of the Medicaid Inspector General, where the office of legal affairs is also sympathetic, but unable to help, and so forth.

#2 Permissible grounds for routine denials of purchased healthcare benefits in NYS and limited “appeal” of denials available to New Yorkers

More ominous than the many billing irregularities consumers are left to resolve with the billing parties, a patient can be denied needed medical service without explanation.  Permissible corporate reasons for denying service are things like incorrect site-specific provider NPI number and improper CPT pre-authorization codes.  These valid grounds for denial are unrelated to an individual consumer’s MOOP, which comes into play more for billing.  There is nobody in New York State a patient can appeal these denials of service to, except to the insurance company itself.  

Immediately before I was diagnosed with a serious kidney disease, in January 2017, I attempted to resolve some issues I’d been having with my then insurance provider, Empire Blue Cross. This was before I switched to Healthfirst, which has a series of nephrologists I’d been referred to, listed as ‘in network” who, it turned out, were not.   Here is the slightly overwrought grievance I wrote when I was a customer of Anthem/Empire.  It reflects the frustration of someone caught in this ‘regulatory’ vacuum:

Grievances – Anthem/Empire Blue Cross Blue Shield “Health Plus”

Grievance 1:  lack of internal complaint procedure for aggrieved customers

After being chided by an Empire representative for never filing a written complaint about any of the grievances detailed below, I attempted to do so on-line.  Logged in automatically under my former bronze plan ID there was an on-line complaint form, easily located.  I was unable to update my member ID info.  A web support representative at Empire walked me through changing the new log-in.  On the website for the “Essential” plan there is no complaint form.

I was also told by web-support/claims representative Laurisha that there is no internal mailing address for submitting a written complaint to Empire and that company policy was not to divulge the name or contact information of company executives.   The rep told me she could take my complaint orally over the phone.   I decided to try my luck with the original claims person I’d just spoken to for an hour.  Nobody was able to connect me to her.

Someone at claims found this answer for me, while looking for the physical mailing address to send a complaint directly to Anthem/Empire.  He told me it was printed in red, as I will reproduce it here:

Essential Plan members do not have a right to file complaint appeal (sic).  If they need assistance filing a grievance or appeal, they may also contact the state independent consumer assistance program at:  Community Health Advocates, 105 E. 22nd Street, NY NY 10010 or 888-614-5400 or email at cha@cssny.org

source:  Anthem’s National Contact Center Document under NY market tab for “Essential” plan updated as of 12-14-16 at 7:56 a.m.

Grievance 2:   unresolvable bill

8/17/16 I went to Madison Avenue Radiology for an x-ray and two sonograms.  I had referrals for all of them.  I got a bill from Madison Avenue for $1,324 for one of the sonograms.   

On 10/19/16 I spoke to a representative at Empire who spoke to the provider, to a person she told me was named Daniel.   I then spoke to Daniel who agreed the $1,342 had been billed in error and told me I’d receive a corrected invoice for the $25 co-pay.  

The next invoice I had, in December, was a third notice from Madison Avenue Radiology that I owed $1,342.  This time Ty at Empire told me she called the provider, who denied ever speaking with me, and that I owed the entire amount, for reasons I could find in the Essential Plan handbook she offered to send me.  She herself did not know the reason a kidney sonogram was covered and a pelvic sonogram was not.  She told me I was responsible to pay the $1,342.  When I asked to speak to a supervisor she told me no supervisor was available.  

(Months later this bill was eventually reduced to a $25 copay)

Grievance 3:   fraudulent referral to cardiologist

I was referred, by Empire, to a cardiologist named David Sahar.  I was given his site-specific NPI number to see him at his 3050 Corlear Avenue office, I sent front and back of my insurance card to his receptionist who confirmed that we were good to go for a December 15 follow-up to my November 18 Emergency Room visit/hospitalization.   Ten minutes into the consultation the nurse who was interviewing me was called away and when she returned she told me Empire had refused to cover the visit. The doctor explained he could not risk not being paid by Empire.

Grievance 4:   fraudulent referral to physical therapy

I was referred by Empire to a facility to continue the Physical Therapy I had begun on 11/1/16 at a facility that treated me once and then informed me that they do not accept the Empire Essential Plan.  I made several calls to Empire to find out how to get them in network, as Empire told me they could enroll by calling 800-454-3730.  After a few weeks calling the PT facility and Empire I gave up.   I requested an in-network PT provider and Empire sent me to an address that turned out to be a nursing home.  It did not offer PT to outpatients.

Grievance 5:   incorrect information; false promises of help from customer service

I called on 12/30/16 in an attempt to resolve these issues, the bill and the two denials of coverage from providers I’d been referred to by Empire. I was told by Joan that the “service not covered” code came up at the cardiologist’s because, likely, an incorrect CPT number had been called in, or possibly the doctor’s office had failed to obtain a prior authorization from Empire’s medical management office, both the fault of the doctor’s office. Empire, I was told, had done nothing wrong.   Joan had no explanation for why I was sent to a nursing home for PT or why the kidney sonogram had been covered and the other one not covered.   She offered to send me the handbook so that I could read it and find out for myself why one body part is covered and another is exempt from coverage for the same diagnostic procedure.  

Joan transferred me to someone who said she was a supervisor.  She identified herself as Julie, at the New York Call Center, assured me she was the only Julie there and that I’d have no trouble finding her.  She noted that I’d never filed a formal complaint about any of these issues and promised to research and get back to me with the answers on Tuesday, 1/3/17 when the office reopened.   Regarding the PT, she gave me a number for a third party vendor called Orthonet.  She incorrectly informed me that they could answer any and all PT-related questions.  When I called Orthonet the receptionist there told me Orthonet’s only role is to authorize services for PT once a provider makes a request to treat a patient.  

When I got no call from Julie at the NY Call Center I attempted to reach her.  Ashanti D, user ID AF09740, was very helpful, even giving me the conversation reference number I52146704.   She told me that without a last initial or employee ID number it would be impossible to look Julie up.  The NY Call Center could not be reached directly by Empire customers, it was an internal number and Ashanti looked it up and transferred me to it.  After a long hold the phone rang three times, then the line went dead.

Grievance 6:  improper billing practices

I received confirmation of my payment for December and January two weeks before this arrived:

Screen Shot 2017-10-11 at 5.07.10 PM.png

Grievance 7:  instead of promised return call, customer service survey

Attempted Customer Happiness surveys asking about each of these “customer service” experiences, by telephone and email.

To show that the corporation is not without a certain sardonic sense of humor, I had a solicitation call from an Empire representative, on 1/4/17, thanking me for my business and offering her assistance in renewing me with Empire so there would be no interruption of insurance for my health care.     

#3 The New York State of Health Marketplace

Errors are not easy to resolve at the New York State of Health (”NYSOH”). Answers to routine questions vary from representative to representative. There is a wait of several months to have even the most simple mathematical mistake by the NYSOH corrected, and one must go through a quasi-legal appeal process before NYSOH will correct its error.  Attached is a recent decision by a hearing officer that ordered NYSOH to correct an easily detectable mathematical error they had committed months earlier.   

Note that any employee of NYSOH could have used the online calculator on their website to instantly verify their error, generated automatically by their website (it is easy to instantly lose insurance coverage at NYSOH, hard to regain it), a mistake that took months to have corrected and resulted in the customer being forced to overpay by almost 100% until they did.

Compounding the aggravation of resolving problems with NYSOH is the policy of its director, Donna Frescatore. Representatives are specifically instructed not to divulge the director’s identity or any way of reaching her office. I have confirmed this policy many times, with many different NYSOH representatives.

#4 Common healthcare billing irregularities in New York State

The PPACA, whose primary drafter, Liz Fowler, went back to work in the health industry after her legislative work was done, apparently contains no provision that the cost of a medical service must be divulged to the patient before the medical service is performed.  

The doctor’s office or hospital cannot tell you the fee until the insurance company sends them a statement.  The insurance company cannot predict the fee until they get the provider’s bill.  The insurance company then eventually sends the patient an Explanation of Benefits, (“EOB”), detailing all charges, payments made and the patient’s responsibility for whatever part of the negotiated rate insurance has not paid.   It is like eating at a restaurant with no prices on the menu, and being sent a bill for the meal weeks later.  Except, of course, that it is not a meal at a restaurant, it is often a matter of life or death, or, at least, of health-related stress.

My kidney biopsy, for example, may cost the patient anywhere between zero and many thousands of dollars.  Simply no way to determine the cost prior to delivery of the service, under current law.  I had the procedure on May 26, I got the most recent EOB related to the procedure on September 28.  In the intervening four months, I got many bills from the hospital.

Though there is probably nothing your office can do about this particular practice, I offer it as an illustration of the scope of the challenges facing New York healthcare consumers.  I provide the following letter to the CEO of Healthfirst as a snapshot of the general billing madness under our current ‘regulatory’ scheme.   

Pat Wang
CEO  
Healthfirst
100 Church Street
New York, NY 10007

pwang@healthfirst.org

September 26, 2017

Dr. Ms. Wang:

I appreciate that you allow your reps to give out your contact information to customers who can’t otherwise resolve issues with your staff.   This encourages me to think that you might be helpful in resolving an aggravating billing situation that has been ongoing for months.    I applaud your willingness to be contacted, it shows integrity and is in stark contrast to the policy of Donna Frescatore, director of the “New York State of Health” (NYSOH) ordering her reps not to divulge her name to callers.

I request a corrected bill and an accounting showing my remaining credit toward premium payments.  The credit situation is described below.

During an August 25th call to Healthfirst to try to resolve the issue of incorrect bills being sent to me, my “case” was assigned an “escalation number” (347-79-923).  I was promised an accounting, showing payment history and current credit toward future premiums.   I received instead a notice, dated September 8 and signed by Christopher A. DiMarco, threatening me with cancellation of my health insurance for a claimed past due balance of $28.   

On September 19 I called Healthfirst and was assured that credit had been applied and my September premium paid in full.  I was also informed during that call that “finance” had included no notes on my account.   I could not be sent a simple receipt for payment or anything indicating my remaining credit.  I was assured by an extremely sympathetic rep that my account was paid through October, with credit remaining toward November’s premium.

Attached is the invoice I received on September 25.   It seeks payment of $482 for October (plus a past due amount), nonpayment of which will result in losing my health insurance (as I begin treatments for kidney disease and skin cancer).   It has been mailed to me in error.   I have a credit of several hundred dollars due to overpayments made as a result of NYSOH’s error.   NYSOH incorrectly denied my subsidy for 2017.   It took months, and a ruling by a hearing officer, before NYSOH was ordered to retroactively restore the subsidy, about fifty percent of the premium.  

As a result of NYSOH’s error, I was required to pay Healthfirst the full premium from February through June.  When I got a bill for July, I called Healthfirst and learned that a credit had been applied for my overpayment.  After payment of July’s premium the rep calculated my remaining credit at $876.

Since then it has been a health insurance headache every month.  In another context, it would be tempting to characterize the attached invoice demanding payment for a premium I have already paid as an attempt at fraud.  I am sure it was sent to me in error.    Please have somebody update my account and send me an accurate statement of my payments and remaining credit.

(invoice attached here)

Thanks,

 

A short time later, after a call from one of Ms. Wang’s assistants, I got a corrected bill that demanded payment of -$183 on or before October 1.