A Mommy Story

I was thrilled to find out earlier this week that a health insurance claim that had been pending for nearly a year was finally being processed.

Yes, eleven months and a week to process one claim. Crazy, right?

The claim was for a test I had done last October after my doctor was concerned with some odd symptoms I had recently experienced. She recommended an abdominal ultrasound to rule out ovarian cancer. (Spoiler: everything was normal, other than a slightly out-of-position ovary. Yay!) Trusting my doctor, of course I had the test done.

At that time we had only recently obtained health insurance. Since we were uninsured before that, we had a one year waiting period for any “pre-existing conditions” and when we signed up for insurance had to provide the names of any health provider we had visited in the last year so they could obtain our medical records to determine what pre-existing conditions we might have.

Since I had never experienced anything like this before, I wasn’t too worried. Our insurance sent a letter shortly after the test stating they needed me to sign another permission slip to obtain my records before they could process the claim. I authorized all of it again and considered it done.

Then I began getting letters from the outpatient center at the hospital where I had the test done, asking me to follow up with my insurance because the claim still hadn’t been settled. When I checked with my insurance, they told me they were waiting on my records from a grocery store clinic where I was treated for strep throat once. I again authorized them to send another request for my records, and also pointed out that these grocery store clinics couldn’t diagnose anything that would be relevant to the test I had done.

This entire scenario repeated two more times. Maybe three. I lost count.

Over the summer, I then received a bill from the hospital, telling me they had received three denials from insurance due to missing information and so would start the billing clock against me. I owed $2,097 for an ultrasound, and please pay within 30 days.

A flurry of calls to the insurance company started again, asking why this still hasn’t been processed. They told me they were still waiting on my records from my strep throat visit before they could declare that I wasn’t trying to get coverage for a pre-existing condition. I was so upset at this point. What did I have to hide? I signed away all of my rights so the insurance company could dig up any medical info on me that they wanted to – how was it my fault that the clinic wasn’t complying with their request?

I was angry and scared at this point. Angry that the processing of a claim could be held up due to a strep throat visit and angry that I even had to deal with a pre-existing conditions clause when we pay a large premium every month just to then have a $1000 deductible per person. (Well, it was $1000. It’s $2500 now.) And I was scared that the insurance company would continue to hold up the process and refuse to pay, which would leave us in the position of accepting the entire bill or possibly going into collections and hurting our credit score while we continued to wait.

The customer service reps at the insurance company were very understanding, I will admit. They agreed it was ridiculous and wanted to help however they could. Finally, last month one rep looked through the history of this claim and said, “You know what? I’m going to send this on to claims processing again, and I’ll put a note on it pointing out that the grocery clinic can only handle minor illnesses anyway. Let’s see if we can get them to forget this and get it processed.”

It took nearly a month, but then I looked at my online account and saw it had FINALLY been processed.

It’s not a perfect happy ending, of course. Insurance declared that the “allowable” part of the bill was only $964.62 and so that became the new total. Of that total, they paid $111.78 and left me with a bill for $852.84, the remainder of my deductible from that year. We’ll still have to set up payments with the hospital for that amount, but at least it isn’t as bad as $2,097.

What really drives me crazy is the new bill after the insurance processed it. Because I had insurance, the hospital is accepting $964.62 as the total bill for the procedure. But had I not been insured, I would have been responsible for more than twice that amount.

So those unable to get insurance are not only afraid of ever getting sick or hurt because they have no safety net in place to help cover those bills, but when they do need care they’re hit with a bill that is much larger than what the provider will get from someone with insurance.

I’m so glad that my tests were normal. I can’t imagine how much worse this would be had I been sick and needed treatment, all while trying to fight for coverage. And that’s WITH insurance. My experience is completely how the old system works – the Affordable Care Act (aka “Obamacare”) provisions that relate to this story have yet to go into effect, although I can’t wait until they do. Our daughters are already seeing the benefits from it, and I’m looking forward to those same benefits and protections.

I know there are good people who do good work at health insurance companies. But I still believe that a health insurance company cannot provide effective medical coverage of their members when they have profits to make each year and shareholders to please. It’s an unpopular belief to many, but I don’t believe health insurance should be a for-profit industry.

While I’d prefer universal health care, I’m willing to accept the idea of private, universally non-profit health insurance companies, where any profits beyond operating costs are rolled back into health education and research, programs providing new ways to encourage preventative care, decreased premiums and incentives for proper maintenance of health conditions. (This would be the nurse in me speaking.)

I know health care is a hot button topic during this election year, but I believe it’s far more than a talking point. Whether you’re a fan of the Affordable Care Act or not, I think we can all agree the old system is not effective and needs reform. I’m not 100% happy with the new system being rolled out, but I’m ready to give it a chance over dealing with the current one.