Obamacare 101

You know it’s a well-designed, consumer-friendly health care program when the second item on the phone menu at your state’s private insurance health exchange is:  

“Press two if you are an in-person assister which includes navigators, brokers, certified application counselors and health plan facilitated enrollers.”

Death by American Healthcare (part 3 of 22,000,000)

I was lucky enough, after more than two months in the wilderness, to get an appointment with a nephrologist who seemed to be very well-liked by his patients.   Sekhnet located this doctor for me, by persistence and almost pure chance.  He was not listed as a participating provider in my health plan, but Sekhnet’s call to his office confirmed that he accepted my insurance.  The only bad news was that his next available appointment was September 19th, almost four months after the biopsy confirming my progressing kidney disease.   I had a call back from his office Tuesday, could I come in Thursday? On Wednesday, the next time my primary care doctor was available, I neglected to get a new nephrology referral, something that is the patient’s sole responsibility.    

Thursday I found myself at the nephrologist’s office without a referral.  My fault, though somewhat understandable, due to the last minute nature of the changed appointment.   I called my doctor’s office and spoke to his service, who informed me he was off on Thursdays.   She promised me a call back, but as I ‘d never had a call back from him, I had my doubts.  Ten minutes later I had a call back from someone in his office, offering to try to get the referral faxed over.  Problem solved, or possibly not.

The problem was, my insurance company requires an Emdeon electronic referral, according to the new doctor’s receptionist.   A faxed paper referral won’t be accepted, she told me, though it had been accepted by the prior nephrologist’s office.  There was a discussion of back-dating the referral, something I’ve been told is insurance fraud.

“Just to be safe,” the receptionist told me, “let’s have you sign this, to avoid a surprise bill.”  The form she gave me stated that the nephrologist did not participate in my plan, was out-of-network, and that therefore I was responsible for paying the full cost of the visit.  

I asked what the cost of the visit was and the receptionist told me she had no idea.  They cannot tell you the price of any medical service, under Obamacare, until after the service is rendered.   It’s a menu with no prices next to anything, the waiter just keeps smiling and tells you not to worry, that you will be billed in thirty days.  It’s fucking insane.  “Just to be safe,” I thought, and then told her I couldn’t sign a paper saying the doctor wasn’t in-network when he was.  I pointed out to Sekhnet, who assured me that she would pay for the visit, if it came down to it, that by signing this, agreeing to pay “whatever”, I was waiving any defense under the recent Surprise Bill amendment to Obamacare.  Even though the bill would, indeed, be a surprise.

The receptionist had another idea.   Call my insurance company and make the doctor my primary care doctor, he was an internist as well as a nephrologist.  This way I wouldn’t need a referral.  The call to my insurance company lasted for 29 minutes.  There were a series of hurdles and I was placed on hold several times, listening to muzak, the last patient of the day, waiting in the doctor’s empty waiting room, earphones in my ears.  Toward the end of this endless call the doctor passed by and I asked if he had any IV valium.  He smiled and told me not to worry, he was in no rush.  

There followed a discussion of his office location.  I told Karen, at the insurance company, that I was at 161 Madison Avenue.  She told me I could only see the doctor at his East 88th Street office.  I repeated this out loud and the receptionist, who by this point had already hugged Sekhnet twice, nodded emphatically that it was no problem.   “Tell her you’re at 88th Street,” she said.   I have a hard time with an outright lie, so I said “88th Street, fine.”

I was now at the last hurdle: a three question questionnaire about my reason for switching primary care doctors.   The last question was about convenience.

“Is the location of this doctor’s office more convenient for you?” Karen asked me kindly.   Not really, I told her.  I explained that the doctor I’d been seeing was half a block from my house and that this doctor was located about an hour from my home, but that I wanted to switch anyway.

“Is the location of this doctor’s office more convenient for you?” Karen asked me again, prompting me.  I repeated Karen’s question out loud for the receptionist and Sekhnet, both now actively coaching me, nodding like two mad women.  

“Yes,” I told Karen, “much, much, much more convenient.  Thank you.”  She thanked me, the transfer was done, I was able to see the nephrologist.    

When the nurse began taking my vitals I heard Sekhnet’s agitated entreaty from the waiting room.  “Don’t take his blood pressure yet, he just got off the phone with the insurance company!”  I told them both it was OK.  My pulse was 57, blood pressure 122/82.   I told them I’d become so used to being screwed around by the insurance company that it rolled off me like water off a duck’s back.

The young doctor smiled again when I apologized for being late (it was now an hour after my original appointment time).  We discussed my idiopathic membranous nephropathy and he told me candidly that the reason there is not more recent research on the disease, which is not as rare as the lack of research might suggest, is that there is no pharmaceutical in development.  The drugs used to treat the disease have been around for a long time.   When a new pharmaceutical is in development that drives research.  “Death by American Healthcare,” I thought, but nodded thoughtfully instead.

He was indeed a very likable doctor.  The upshot was roughly the same as at the previous nephrologist, my best bet was medicine’s only bet: immunosuppressive therapy.   He would refer me to the doctor he trained under, who specializes in glomerular (a word I still can’t pronounce– definition below*) diseases like mine.   There was no immediate rush to begin treatment, he said, as the disease progresses slowly, but his senior colleague was the expert and would fully inform me of everything I needed to know.  We shook hands and bid each other goodbye.   Sekhnet was beaming from ear to ear.  

“You should keep this doctor,” she told me, “even though it’s inconvenient to get to his office.”  I told her I’d think about it.  This morning at 9 a.m. he called to discuss the results of yesterday’s blood test.  We’ve been playing phone tag since, but it was impressive to hear back from him so soon.


*      glomerulus:  a cluster of capillaries around the end of a kidney tubule, where waste products are filtered from the blood.

Informed Consent

We live in an imperfect world, a point that needs no belaboring.  We like to believe that Reason governs human affairs, but most often we can trace the behavior of societies, groups and individuals, to fear, hatred, hopelessness, greed and other mostly non-rational impulses.  The great democracy we live in, for example, is currently presided over by a person who is not a clown as much as a menace.  He was put into office by the galvanized forces of fear, hatred, hopelessness and greed.  He cannot seem to control his impulse to lie.  Here’s Amy on a recent presidential lie the White House just admitted was a lie.  

You can go mad watching the news, dominated by this stubborn attention seeker, unless you believe, as up to 33% of our voting populace seems to, that we live in a time when minorities and poor people are completely out of control, rich job creators are being tortured by our government, the media lies constantly and that only good old fashioned law and order can “Make America Great Again.”  

Going mad is not the best option, at least not as far as I can see.  I’ve made it my daily practice to try not to go mad, no matter how tempting it may be to go there.   One form of this daily practice is writing, in detail, to make whatever I am dealing with as clear as possible, to myself and to anyone reading.  

Transparency, and its deliberate denial, has long been a big issue with me.  It comes from a childhood where blame was shifted on to the children for the problems of adults.  Perhaps my father was incapable of answering my anguished question about what happened to grandma and pop’s twelve siblings (shot in the neck in a ravine, as it turned out) but it was wrong of him to blame me for being anxious about it.   If Reason is to guide us in trying to live reasonable lives, we have to have the information we need to consider things fully and make reasoned choices.  

We have that great phrase from the Author of Liberty, about ideal government: “deriving their just powers from the consent of the governed.” That has been changed slightly in practice, if not rhetorically.  A more accurate statement in 2017 would be “deriving their indisputable powers from the acquiescence of the systematically manipulated.”   Our elections are decided by a plurality of voters casting votes after watching fantastically expensive advertising campaigns.  The winning product is the one with the most effective attack ads on the rival product.  The government that results from this process hardly amounts to one ‘deriving its just powers from the consent of the governed’.  

It is a mark of patriarchy to rest on its right to simply be right.  No discussion is required, if one party has all the power and the other party has none, when the powerful party declares “because I said so.”  You cannot give informed consent if you are not informed.  There is nothing mysterious about this formula.  

As in the larger society, so it goes in individual interactions. If patriarchy is the final word, from top to bottom, and you have a problem with that, you are the one with the problem.   The impulse to be right is a powerful one, and we are all conditioned to argue that we are right whenever we feel challenged.   There is a more merciful orientation, true, and the world would be better if more people operated under it, but that is not the problem of patriarchs.

I called the National Kidney Foundation’s helpline.  Marjorie was great, though, in her own words, not very knowledgable about anything but the basics.  She’d never heard of my idiopathic kidney disease, for example.  She was pleasantly surprised to learn that up to 40% experience a spontaneous remission from this disease of unknown cause.   She told me that most nephrologists, going by what she hears every day, are arrogant jerks.  She said the profession apparently attracts these types.  I told her my experience did not contradict this.  

Here is my problem with the insecure, defensive, arrogant jerk who was treating me, until two months ago.  She did not feel the need to answer questions, was dismissive, manipulative, untruthful, incapable of sincere apology.   Aside from those things, which tend to increase a patient’s stress level, I’m sure she is an excellent doctor.  My biggest problem, now that I have learned much more about this disease and proposed treatments, is her refusal to give me the information I needed to make an informed choice about a side effect-rich course of IV steroids and toxic agents designed to shut down my immune system.  This therapy is recommended only for high risk patients, all others are treated with supportive therapy and counseled about diet and exercise and watched for signs the disease has progressed or begun to wane.

I wrote this, earlier, to send to this gender-neutral asshole nephrologist, for my physician friend’s feedback:

You seem to have concluded that I am a high risk idiopathic membranous nephropathy patient and that therefore immediate immunosuppressive therapy is necessary.   I’d appreciate if you could set out the factors you considered to determine that I am in this high risk category, as these were not explained to me in any detail.

Thank you

Full transparency, which would have called for a “Fuck you” instead of “Thank you” at the end, must sometimes be sacrificed for the greater good.  In this case, I need to know what tests and other factors she considered, in the absence of the standard 24-hour urine test, to determine that I need to begin a chemotherapy regime immediately. 

We all tend to phrase things in terms of our own concerns.  I don’t mean to keep harping about my kidney disease, although it is on my mind.  It serves as a perfect metaphor for many killing situations that are just part of the status quo in our competitive, materialistic USA! USA!!!   If you are not afflicted by a serious disease, the many problems of Obamacare, the calls for its repeal, are abstractions, troubling though they may also be.  If you are unable to get treatment from any of the highly recommended nephrologists you’ve been referred to, doctors allegedly in your insurance network, you are, as they say: fucked. 

Surviving the American Death Panel

When healthcare is a profit-driven, corporate industry, as it is here in the wealthiest country in the world, competitive companies and some individuals will become very rich participating in it.  Sadly, people also die under such a health care system, which tends to be as expensive as the market will bear.  Those who don’t die often face personal bankruptcy for bills incurred during life-saving medical interventions.   These are, one supposes, the price we all pay for freedom, for the exalted Free Market.   Americans should be free, under our system, to pursue unlimited wealth and damn the torpedoes.   Sick people die, poor people die, not our problem or responsibility, as individuals in the Free Market or as a society.

Part of the corporate structure is hierarchy, in which each level is accountable only to the ones above.   This produces natural caution, a reflex to self-justification and a tendency to ass-covering.  A related side of corporate life is patriarchy, for lack of a better word.  Corporations tend to dictate terms, be rigid, owe no explanation, erect obstacles to information and have procedures to ensure that their policies are inviolable and untouchable by courts of law.  They are not known for flexibility, fairness, even common decency.  They behave this way because they can, because they write the laws that govern them, finance the elections of their bought and paid for candidates.    

What does all this have to do with my own inability, so far, to see either of the two nephrologists recommended to me by a doctor I respect?   I shall tell you as briefly as I can, as I suffer silently with idiopathic kidney disease.

By chance, on the recommendation of an acquaintance of  a friend, who got the doctor’s name from a list, I saw a patriarchal nephrologist, a female patriarch by chance, who dismissed my questions about nutrition, life-style, alternative treatments, supportive therapies, recent studies of my disease I could read.  None of these things would help me, she said.   She urged me, from our first meeting, to immediately begin side-effect rich immunosuppressive therapy.  Months 1, 3 and 5 begin with three consecutive days of IV corticosteroid infusions and it takes off from there.

This immediate immunosuppressive therapy is called for, I eventually learn, only for high-risk patients, those with a high daily proteinuria count and other risk factors.   All other patients are advised to wait, and watch, as a cure without this regime is about as common as a cure with the sometimes devastating immunosuppressive treatment.   The statistics argue for waiting, and rechecking levels every couple of months absent a medical determination that you are in the high risk category.  

This nephrologist assessed me as a high risk patient without ever checking daily proteinuria levels and even though my kidney function is normal.  She did not share her diagnostic findings with me, beyond saying the disease was getting worse and urging me to start with the IV steroids.  She never mentioned a risk category or the reason for the haste.  She told me over and over that I need to start immunosuppressive therapy right away.

I was never told why I am at high risk as I was being pressured into starting the immunosuppressive therapy ASAP.  Patriarchs and corporate types do not owe such explanations.  They offer the service they deem correct.  To this end, I was manipulated into having a medically unnecessary biopsy done.  The necessity of the biopsy was that it is the last part of the protocol before immunosuppressive therapy.  I was told it would show the precise stage the disease has progressed to.  I’ve since learned it cannot really show this with any precision.  

For a long list of reasons, I lost faith in the defensive, argumentative, dismissive nephrologist.  I simply could not trust her, in spite of her strenuously extracted, and meaningless “unconditional apology”.   She was about as sincerely repentant as Trump was about being the nation’s number one Birther.  

I got a recommendation for a senior nephrologist.  As luck would have it, he was in the same practice group as the original patriarchal nephrologist.  I was told the two doctors would have to discuss the switch, as they generally did not see patients of other doctors in their group.  I was told my nephrologist needed to consent to the change and the other doctor had to agree.  

My nephrologist seemed to consent in a terse message: I have instructed my front stuff.   Her front stuff told me, each time I called, that the doctors were still deliberating.  After three weeks of calls to make an appointment I was told that they never, under any circumstances see a former patient of anyone in the group, it was an inviolable rule.   As Jane Fonda’s character in Grace and Frankie said the other night, during a vexing moment: “fuck me in the eye!”

I went to a good deal of trouble and expense to get another recommendation.   Thankfully this doctor was on my health-insurance plan.   I called the number the insurance company had listed for him, to make an appointment.  It was a wrong number.  I called the insurance company and was given two more numbers, not available on their on-line participating providers list.   They connected me to the doctor’s office.  

The doctor’s receptionist informed me that they do not participate in the plan, that Healthfirst has them listed incorrectly.  They only take insurance patients for the private dialysis center they run, but are not participating nephrologists for any other purpose.  This receptionist was knowledgable about insurance law, telling me, for example, that it is a crime to pay a doctor out of pocket if you have insurance coverage.  She referred me to an NYU nephrology group, the same one who had treated me so unethically. She was not all that sympathetic, in my opinion, and after snarling a bit, and cutting me off, hung up on me before I could tell her to fuck off.

Which was just as well, I don’t find it very satisfying or effective to tell unreasonable, nasty people that they are unreasonable or nasty.  In the case of this receptionist, there was really nothing more she could do.  That I had one final , quick question, which would have the same answer as all the others, was nothing compared to her duties to the patients waiting in her office as she was wasting time talking to a non-patient with an attitude problem.

“If you like the doctor you have, you can keep that doctor,” promised President Hope and Change, the former Compromiser-in-chief, while negotiating against himself during the passage of Obamacare.  If you don’t rate him highly on that promise, remember that he never came in America’s mouth.  Not explicitly anyway.  The people we have in there now, hoo boy, talk about death panels and forcers of unwanted touching.

My task now is to figure out how to use this ill-designed system against itself to get the treatment I need for this potentially fatal disease I am up against.  A disease that, thankfully, seems to take a long time to finish you off and that, as mysteriously as it comes, sometimes disappears by itself.  

I don’t know how interesting this has been to read, if at all, but I note that the knot in my chest I woke up with seems to have unloosened itself by a turn or two, and that is a very good thing.


Republican Health Care Plan

I inadvertently gave myself a nice taste of the shit sandwich that is the proposed Republican Health Care Plan, Trumpcare, as far as I can tell from the details I’ve learned.  I heard an interview last night that laid out the main differences between Obamacare and Birthercare and realized– fuck, I did it to myself in 2017!  The Republican plan would greatly increase premiums, co-pays and deductibles on older Americans, an age-based pricing scheme not currently allowed under the ACA.  I’ve had a taste of that in 2017, hoping for better care than I had in 2016 I am paying 600% more for the same coverage I had last year.  You don’t need me to tell you what a shit sandwich tastes like.

Obamacare, basically Romneycare, which was in part based on the Heritage Foundation’s conservative plan to keep private industry in charge of American health care, had two or three major improvements over what came before.  In exchange for the mandate that would force younger, healthier people, on pain of a tax penalty, to buy insurance, thereby funding the pool for older, sicker citizens, American patients were freed from the industry’s “pre-existing condition” loophole and ensured delivery of what are deemed essential medical services.   It used to be possible to sell insurance with serious limitations on, say, preventative services.  No more, under Obamacare.

The details of the secret Republican plan, the culmination of a seven year partisan battle against Obama’s health care law, a law they’ve called “worse than slavery”, probably worse than any holocaust, were to be revealed a week before the up or down vote.  No debate was planned because Republicans, being in the majority, believed, at first, that they could pass the law on a strict party-line vote.  When some of the details were revealed, including the CBO report that 22,000,000 Americans would lose health insurance under the proposed law, the deal quickly went south.  It’s hard to cast a principled vote for something with a 12% public approval rating.  Even in today’s lockstep party-line political environment.

There were tremendous tax breaks to the wealthiest Americans as part of the Republican plan.  This would fulfill one promise the current president made to his wealthy friends and more than reverse the tax hike Obama instituted to help fund Obamacare.   Part of the Republican plan shifted more of the cost to older, sicker customers.  Another part removed the mandate but instituted an alternative punishment, a six month waiting period for enrolling if you allowed your prior coverage to lapse.  Under the Republican plan the customer would pay a higher percentage of the cost of medical care, from Obamacare’s 70/30 split to something much fairer to insurance companies, like 58/42.  A sixty-four year old with an income of $26,000, currently paying $1,700 a year under Obamacare, would see the cost of health care increase to more than $6,500 in premiums.   That number does not include increased co-payments and out-of-pocket expenses, devilish little details that could add up to another quarter of that person’s income.

Fatefully, the Republican plan would eliminate millions from the Medicaid Expansion roles.   Obamacare increased the threshold for Medicaid type coverage to people up to 150% above the artificially low poverty guideline and provided subsidies for people living on up to 400% over the poverty line.  11,000,000 to 14,000,000 Americans now have low cost health insurance that is virtually Medicaid.  

The costs of Medicaid Expansion are paid mostly by the federal government, the federal contribution is currently at 95%.  The Republican bill scales it back 5% a year from 2021 to 2014, until it makes the program impossible for states to continue.  States, under the Republican plan, would also be able to get waivers for in-state insurers to opt out of Medicaid expansion programs and offer less than the Essential Benefits mandated under the ACA. The Republican plan would allow patients currently receiving Medicaid Expansion benefits to be grandfathered in, but it is also still famously easy to be chucked off insurance, and once chucked, it’s chuck chuck bo-buck banana fana fo fuck to you for the rest of your earthly lifetime, under the Republican proposal.  The proposed bill also slashes funding for Planned Parenthood.  USA!   USA!!!!

I’ve written critically of Obamacare, which sucks in many ways, especially its fundamental deal to keep the foxes in charge of the sickening American health care henhouse.   That said, there is no question that it is more decent than the unfettered, bare knuckles medical insurance scheme that preceeded it.  People who receive coverage under the ACA, whatever our many frustrations with the idiosyncrasies  of the industry-written plan, prefer it to the way things were before.  Most Americans, it seems, agree.  

Is there still a serious debate over the “pre-existing condition” loophole that saved insurance companies billions while condemning countless sick Americans to death?  Even Mitch McConnell’s bill doesn’t restore an insurance company’s right to refuse to sell insurance to somebody because they once suffered from an expensive medical condition.

It seems apparent that a big part of the motivation for this Repeal and Replace mania is a vicious partisan hatred of this nation’s first mulatto president.   There’s greed by the wealthiest, sure, you always expect a certain amount of that from wealthy materialists obsessed with getting every government advantage to help them become wealthier.  There’s the old partisan bickering that has become a larger and larger feature of our political landscape since Reagan.  

To understand the Republican jihad to repeal Obamacare we must not discount hatred, pure and simple, of the well-spoken half black man for whom the bill is named.  He comported himself with dignity even as Mitch McConnell announced that the Republicans were dedicated to making sure everything the president proposed failed and a coyly racist movement known as Birthers publicly, continually and counter-factually attacked Obama’s legitimacy to be president.  The highest profile “birther” was the celebrity brand who is the president now.

 “Birthers” spoke the lingua franca of millions of Americans, and said it loud and proud: “this man is a nigger and we do not have to have a nigger president of the United States.  We will simply not allow ourselves to be ruled by a nigger.”  If you doubt this widely shared sentiment, look at a large part of the current president’s base.  Millions of readers of websites like The Stormer, named in homage to the Nazis infamous Der Sturmer, whether affiliated with a hate group or not (and these mothercuckers have proliferated wildly since Obama’s election) will have no problem endorsing this view.  I guarantee that not one of these neo-nazi fucks will ever use the politically correct “n-word” to refer to our former president, except perhaps in gleeful air quotes.  These angry young white men, and their fathers, and grandfathers, voted overwhelmingly for the race-baiting panderer-in-chief, an unrepentant leader of the Birthers.

Are we living in Germany 1938?  I’d like to think not. On the other hand, on the eve of Hitler becoming the full-blown Hitler history remembers, the New York Times opined that the institutions of German democracy were too robust, the German people too cultured and sober, to allow the crass little shit-snot Mr. Hitler to run amok.  Run amok the crass little shit-snot Mr. Hitler did.  I’m not comparing this genius of audacious self-branding to any other would-be tyrant.  I’m just sayin’.   The proposed repeal and replacement of Obamacare would be a giant step toward the final victory of America’s crass little shit-snot-in-chief and the third of the nation on which his legitimacy stands.  

Would it not?

Dining With Cannibals (part one of many)

Long before he ran for president, Senator Bernie Sanders told national treasure Bill Moyers “the business model for Wall Street is fraud.”  It is hard to dispute this description, even as the law winks at and lawmakers and other canny investors profit from the business model of Wall Street.   The business model for American health insurance companies is fraud.   Their profit is based, in part, on their ability to deny services that customers pay for.   I offer the following maddening illustration.

Leave aside the debate over if it was fair to make insurance companies offer reasonably priced coverage (or any coverage) to people with ‘pre-existing conditions.’   I’d argue it is fair, but fuck my opinion.   You can argue whether it’s fair to make insurance companies, collecting decent premiums from consumers, cover an annual preventative visit to the doctor.  You can argue the fairness of it, it’s your absolute right as an American to argue.  You can even elect a living turd to bully his party into dismantling the timid, conservative think tank-created baby step in the arguably right direction for ‘failing American health care.’  I’m here only to point out a concrete instance of the basic business model of American health insurance: fraud.

You are faced with a single choice for treatment of, let us say, chronic kidney disease.   You are being strong-armed toward the one treatment available to medical science:  immunosuppressive therapy, a kind of chemotherapy described as an “atom bomb that knocks out your entire immune system and hopefully straightens out your auto-immune disease when the immune system comes back on-line.”  The treatment involves IV steroids and other agents with possibly severe side effects.   On the other hand, one third of all sufferers of this mysterious disease are cured from it without medical intervention.   Nephrology does not have a clue about this “spontaneous remission”. You seek a second opinion.    You’d like a medical opinion about how to increase your chances of being in this one third who recover from the disease without undergoing a form of chemotherapy.

The only opinion you will get from an American nephrologist is that immunosuppressive treatment is the only medical treatment currently available, and that you’d probably be wise to start before you suffer permanent kidney damage.    You hope for a thoughtful nephrologist, who will not prey on your fear but allow you to make a fully informed decision about treatment, but the rest is a matter of the chance and the doctor’s personal style, whether they listen well and answer questions, return calls, are supportive or dismissive, sensitive or prick-like.  The one I happened to see was a jerk.  Luck of the draw.

Anyway, better still, let’s leave aside the specifics of the case.  To see an out-of-network provider, paid in part by the insurance company, you need to obtain pre-authorization for the visit.  This pre-authorization is granted , based on medical necessity.  The insurance company gives you a number for the doctor to call to get pre-authorization.  They must convince the Medical Management department that the services they provide are not offered by anyone in-network.

Once the case is made, Medical Management renders a determination.  A week later you learn whether or not the visit will be partially covered by insurance.  Without pre-authorization insurance will never pay anything towards the visit.

Provider calls Medical Management.  They are told that the patient they are calling about does not have coverage in his policy for out-of-network visits.  No request for pre-authorization can be made on behalf of that patient.  Thank you for calling, the end.

When the patient is informed of this, and calls the member’s services number at the insurance company, he is told that he does have coverage for out-of-network visits.  The problem, he is told is that the provider did not have pre-authorization.

You point out that the provider called the number you were given to get pre-authorization.   Perhaps they are referring to some pre-authorization for pre-authorization you have not been informed of.   Or perhaps, since they have told the prospective doctor a plain untruth, which forecloses the request for pre-authorization, their business model is closer to fraud.  If you have the ninety minutes to devote to this discussion, and sufficient patience and skill, you can get it worked out and the provider can submit a request for pre-authorization.  For virtually everybody else– bingo! we just made some more money for our CEO.

You get an Initial Adverse Determination from the insurance company.  There is no need for this esoteric specialist, it informs you, when we can provide you a dozen in-network doctors with the same expertise as the doctor who did not answer your questions, the one you don’t want to see anymore.  

You call the insurance company to ask them what the hell this determination means, as it makes no mention of medical necessity or the argument presented, it merely denies the pre-authorization based on the fact that they have many specialists in the same field, as well qualified as the jerk you no longer trust to give you medical advice.

Here’s the kicker, though.  Membership, the only number you can call, as a member, has no record of any request for pre-authorization or any determination affecting you, adverse or otherwise.   You read to them from the determination you are holding.  They seem to believe you, they just have no record.   You are, of course, free to appeal the Adverse Determination, in fact, you have, under state law, a generous 180 days to do this.  They are Member Services, after all, only the Provider side has any of this information.  

It happens again with the next doctor.  “This consumer has no coverage for out- of-network visits, thanks for calling.”  Now it is a pattern, a pattern and practice.  It is part of a fraudulent scheme.  Only my opinion, of course, but can you think of a word that describes this better than fraud?    

“Did you try calling the Provider number?” suggests Sekhnet, thinking outside the box.

I do.  I am patient, I am persuasive, I do not pretend to be a doctor, I state my case.  The representative is understanding, tries to be helpful.  Her hands are pretty much tied.  She speaks to a supervisor.  Tells me only Member Services can help me.  I describe the fraud again succinctly.  She does not disagree with my description of the ingenious scheme that separates these two parts of the corporate brain.  She asks me to please hold while she speaks to another supervisor.  I listen to the hold music for a few minutes.  She returns with helpful news.  

“You can ask for an EXPEDITED APPEAL,” she tells me happily.  The regular appeal takes at least a month.  I ask how long the expedited appeal takes.  She has no idea, but I can find out at Member Services, she believes.  She can transfer me there now, she tells me for the sixth time.

I rest my case, over and over again, on my own head.  I’ve got to finish that fucking letter to the New York State Attorney General, the one who got the current president to cough up a token $25,000,000 to settle the case against him for his fraudulent university.  New York State needs to regulate these lucrative, legally created pseudo-person psychopaths.