ACA Probably Not Affordable – But Who Knows?

October 24, 2013

By Karen

I’ve been writing about the ongoing agony of being individually insured by Anthem for years now, so I should follow up with my 2 cents on the debacle called the Affordable Care Act.

I’m not surprised that we couldn’t get a working website after 4 years. Government bureaucrats are good at discussing problems, never solving them.

Virginia’s Republican governor, Bob McDonnell, is among those who turned his back on any responsibility to help citizens get health insurance in favor of the federal exchange.

I first tried to log on to Oct. 4 and couldn’t get in. I tried again Oct. 23 and it seemed to work better. I didn’t have to create an account to browse the plans — for all the good that did.

Apparently, the quoted premiums are garbage unless you’re exactly 20 or 50, so I accomplished nothing but to upset myself.

Currently, my Anthem policy has an 80/20 split, a $2,500 annual deductible, and includes dental. I pay $392 a month.

Anthem has been cheerily reminding me that I’m “grandfathered” in and can keep this plan. Since it’s outside the exchange, I suspect that means Anthem can continue to stick it to me good with rate hikes, so they don’t want me defecting to the exchange.

I learned that my 80/20 plan is considered “gold” on the exchange. A silver 70/30 plan without dental runs a 50-year-old roughly what I pay now. So, at 59, I assume my coverage will be considerably higher.

I suspect I’m royally screwed no matter what, but I’ll get my insurance agent to confirm that later in November. Hopefully, by then there will be accurate pricing available SOMEWHERE.

It’s exactly as I’ve predicted. With insurance company profits still a factor, and Republicans offering NO alternative but to go backward, it’s going to take more employers dropping health insurance as a benefit, and more Americans going broke trying to pay for insurance before we get serious about single-payer.

Amazing, I find myself agreeing with Ken “Cuckoo” Cuccinelli, our Republican attorney general who wants McDonnell’s job as governor this year. We both think Kathleen Sebelius needs to go.

Her utter inability on The Daily Show with Jon Stewart Oct. 7 to make a clear, compelling case for the ACA, or to give the slightest reassurance it’s going to get better, was shocking.

Lady, you’ve had FOUR YEARS!!

Where was she while the cost of that catastrophic mess of a website TRIPLED and went into the pockets of Canadian software developers? How many hundreds of millions must be squandered to get it right now?

Obama should kick asses and hand out pink slips. Everyone responsible for this disaster deserves to lose their cushy government healthcare and end up on the exchange they couldn’t set up.

The High Cost of NOT Having Cancer

September 8, 2011

By Karen

I’ve been waiting for the bills (11) to trickle in after my breast cancer brush in June so I could wrap my head around how totally out of control our healthcare system is, and how Obama, in fixating on insurance, completely missed the target.

If you’re just tuning in, as the result of a fishy mammogram, I ended up having a benign lump the size of a pencil eraser removed from my right breast.

I was just able to sum up the whole situation in one sentence, but thanks to the wonders of modern medicine, it actually took a month and 5 visits.

Total cost if I had no health insurance…


(Not including the original routine mammogram, which was $345.)

But I do have insurance. After I paid my $2,250 deductible (+ $284 in monthly premium), Anthem paid exactly $2,945.

I owed an additional $513 because Anthem has me on an 80/20 split.

Here’s the kicker: Anthem “disallowed” $17,921 — 76% — of the $23,629, so the total owed was only $5,708.

But if I were uninsured, I’d be on the hook to pay the whole $23,629.

Question 1: If the medical system can continue to function collecting only 24% of their charges, WHY are they trying to rob the uninsured?

Question 2: Why must insured and uninsured alike undergo and pay for physician CYA, providing THEM defense against a malpractice suit? Did I really NEED 2 additional rounds of mammograms and 2 ultrasounds, not to mention that stereotactic outrage where they drilled in and ripped out a half-ass piece of the lump for “testing?”

As soon as they saw that white spot on my mammogram, they hustled me off to a surgeon while everybody said it was nothing. They knew where this was going — or they SHOULD have, since this is their “profession.” Why not just knock me out, do the fucking lumpectomy, and be done with it? It would have knocked $4,532 in preliminary bullshit off the bill.

Instead of playing cute with insurance companies and whistling when hospitals are trying to stick every patient with the full cost of running the place for every moment the patient is in the building, our brilliant lawmakers should be legislating that everybody involved with healthcare GET REAL about costs and stop the gouging.

In the meantime, we schmucks who need the services will continue getting screwed, if not by the insurance companies, then by the medical providers themselves.

PS: And does Bon Secours really need to send a letter before every invoice, telling patients a bill is coming? Is this not silly and wasteful on every level? To top it off, in addition to collecting only 24% of their original billing, they offered me a 10% discount for paying my portion within 30 days (which, of course, I accepted).

And yet they manage to stay in business.

Could you live on less than 24% of what you earn unless your paycheck was obscenely inflated in the first place?

Employer Health Benefits May Go Bye-Bye

May 7, 2010

By Yul

You probably thought it was just a crazy cat’s raving when I suggested that Obama ban employers from providing health insurance to level the playing field. Well, dropping their health benefits is EXACTLY what Big Business is considering.

Rep. Henry Waxman, chairman of the House Energy and Commerce Committee, got steamed at employers for allegedly inflating health reform’s bottom-line effect. He demanded to see all their documentation and summoned the big-wigs to a hearing.

Waxman discovered in internal dirt from AT&T, Verizon, Caterpillar, and Deere that they had all concluded paying fines would be a MUCH lower and predictable expense than their time-consuming, never-ending crap game with insurance companies.

Waxman canceled his hearing and dummied up. So much for Obama’s foolish promise that “you can keep the insurance you like.”

What employers giveth, employers can taketh away.

The country will be better off if they follow through. Companies will have billions more for R&D and hiring. Without Fortune 500 companies to bilk, insurance companies won’t be posting 51% quarterly net income increases.

People who had employer benefits will get a much-needed reality check when they experience the absurdity of 50 inconsistent state insurance exchanges, and the country will be a few steps closer to universal healthcare and making a dent in the deficit.

On another front, WellPoint/Anthem and other insurers have suddenly gone all altruistic, claiming they’ll immediately stop rescinding coverage on the sick, unless the person committed fraud in applying.

Fraud cancellations are about to rise off the charts, and people can go bankrupt twice as fast — paying their own medical bills and the lawyers they’ll need to defend their integrity.

For the insurers, it’s nothing but a set-up to justify obscene 2011 rate hikes. (“We’re covering more sick people now!”) WellPoint was recently forced to back off that 39% increase in California as unwarranted, so they’re going to make everyone else pay. Just you wait.

Learning the Healthcare Claim Game

May 29, 2008

By Karen

What you don’t know about claims coding could cost you.

I had a long-delayed bone scan a few weeks ago, which was $220 on the spot if my insurance didn’t cover it. So I called my insurer, Anthem, to see if it was covered.

Anthem told me that routine bone scans aren’t subject to my deductible and are covered at 80 percent. I’d be responsible for the $40 co-pay plus 20 percent.

This week, Anthem’s “Explanation of Benefits” denied the claim, but knocked $80 off the original price, leaving me on the hook for $140. I’d have paid this if I hadn’t talked to Anthem before the scan, just assuming that everyone involved knew their job and had done it right.

Instead, I decided to find out what gives.

Anthem told me the doctor’s office coded the claim as a “diagnostic” scan for a “disorder of bone and cartilage unspecified.” That isn’t covered, but goes toward my deductible. However, “routine” scans are covered, as I was originally told.

I next phoned the doctor’s office. They said, “Unless you tell us to submit it as routine, we always make these claims diagnostic because that’s what most insurance companies will pay for.”

So now I’m supposed to know how to code claim forms and coach the doctor.

But they did readily agree to recode the claim and resubmit, which should save me $128 after I pay 20 percent.

The lessons here are 1) that you should question every charge because you could be paying big bucks for nothing, and 2) that most physicians will cooperate when it comes to getting insurers to pay up because there’s no love lost there.

And after the wringer Anthem Underwriting just put me through, the last thing I want in my file is an “unspecified bone or cartilage disorder” when my policy renews.

Health Insurers: Medicine’s Boa Constrictors

May 1, 2008

By Karen

Now that my cheaper Anthem health insurance is in place, I’ve been playing catch-up on all my routine checkups and the bills are rolling in.

A few weeks ago, my family practitioner checked my blood and urine.

I just received Anthem’s “Explanation of Benefits” listing a total of 7 Lab/Pathology items for these two tests totaling $276. Of this amount, Anthem paid exactly ZERO.

But the good news is that because Anthem’s in my corner, they tossed off $205.40 as lab greed. So I’m on the hook to pay only $70.60 in “allowable” charges. Lucky me. Nearly 75% off is what I get on this extra medical bill in addition to $378 in monthly premiums.

One $30 charge was voided, with Anthem not requiring me to pay a penny of it. I wonder what frivolous procedure they thought that was for?

I’m not complaining (well, yeah, I am, if only at Anthem’s ironclad refusal to cover preventive care to head off bigger claims in the future), but I’m wondering how healthcare providers survive by getting paid only 25% of what they think their services are worth.

Do doctors just pull these amounts out of their butts? Are they grossly inflating the cost of doing business?

Or are health insurers being allowed to systematically strangle the healthcare industry into bankruptcy as they squeeze every penny they can out of policyholders (individuals and employers), keeping the lion’s share for themselves while they do nothing but obstruct good healthcare?

If you’ve read any of my previous posts on this subject, you know what I think.

We’ve had a step in the right direction just by getting John McCain to acknowledge there’s a problem, but all of the presidential candidates have yet to propose a plan that’s anywhere near as effective as HR 676, the universal healthcare bill that’s been languishing in Congress since 2005.

If HR 676 were to pass, “Explanations of Benefits” and the insurers who spew them would be extinct, and routine preventive healthcare wouldn’t be a luxury people are increasingly unable to afford.

Anthem Cut the Crap (Finally)

March 28, 2008

By Karen

After nearly 3 months, Anthem has approved my cheaper policy. It essentially rolls back my premium two years in exchange for me shouldering more out-of-pocket expenses. I don’t know if I’ll really come out ahead in the end, but right now I’m betting on continued good health.

Anthem put me at premium Level 2. Level 1 would have been cheaper, but here’s how that works:

In 2003 when I first applied, I took no medications and my health was nearly perfect for someone my age. Anthem made me Level 2 by dredging up an old stress fracture in my toe from too much ballroom dancing and a few other one-time things.

In other words, unless you’re 18 and have never seen a doctor in your life, you’ll never qualify for Level 1.

This time my Level 2 rating was for my “unoperated hiatal hernia.” That means it gives me no trouble and requires no treatment – but unoperated sounds scarier.

Anthem explains (bold emphasis is theirs), “Even if you are currently healthy and have no immediate health problems, your chances of needing medical care are greater than someone who does not have similar health conditions or lifestyle characteristics.”

They’re referring, of course, to someone who is already dead.

Apparently, that was the best they could do, since my harmless freckle and a blood pressure reading in the 120s over 80s didn’t pan out as crises.

They were so relentless about digging into my records, I really expected a bump into Level 3 to end up paying even more for less coverage. That’s how individual health insurance works.

So I’ll be saving $110 a month at least until December when they hit me with another huge rate hike and I’m back where I started.

I’m 12 years from qualifying for Medicare. If insurance companies are allowed to continue reaching for the moon for profits, at some point I could join the 47 million Americans who can’t get or afford coverage unless I find some employer to cover me.

Politicians of both parties, please, please, please end this nightmare. Passing HR 676, the universal healthcare bill that’s been sitting under your noses since 2005, would be a good place to start.

Anthem’s Leaving No Stone Unturned

March 15, 2008

By Karen

After getting Anthem lab results on my benign freckle they required but failed to request from my gynecologist, I thought I’d cleared the last hurdle in my 2 ½-month quest for cheaper health insurance. They said it was the last thing they needed.

Wrong! This week I couldn’t get approval without a blood pressure reading – from the family physician who hasn’t seen me in nearly a year because I’ve been feeling fine.

Naturally, the irony was lost on Anthem. Why the sudden concern about my BP just when they’ve got me about to blow a head gasket over their endless bureaucracy?

Anthem claimed they asked for the reading in January, but my doctor had no record of it. Instead, they said just last week they received a strange call from someone demanding my blood pressure numbers who wouldn’t identify themselves, so the practice refused.

I got my doctor’s assistant to give Anthem my BP reading by phone, then went home and phoned Anthem myself to double-check. Anthem assured me again that now they have everything they need.

I’ve paid the higher premium for March because Anthem sent me a late notice. I’ve soon got two routine medical appointments I’d hate to postpone again, but I doubt Anthem will have my new coverage in place. I can see them screwing up the billings and my premium credits for months to come.

Politicians are insane to think insurance providers, with their ingrained distrust and callous disregard for customers, hold the key to our healthcare mess. Anthem has now painstakingly picked over every piddling physical imperfection listed on my application. Being healthy carries no weight with them whatsoever. In so many words, they’ve said they’re dissecting my app because I might have slipped some major health crisis past them – while they’ve been insuring me for the past 5 years.

Translation: “We’re looking for any excuse to cancel you or continue making you pay through the nose, even with less coverage.”

I don’t intentionally single out Anthem, except by my experiences. They’re no more devious than the rest. Patients’ only recourse is to eliminate health insurance altogether by hounding our representatives in Washington to pass HR 676, the universal healthcare bill.

Time to Stake Vampiric Health Insurers with HR 676

March 5, 2008

By Karen

Anthem has had another week to get information on the freckle they’re obsessed with as they agonize over letting me have cheaper health insurance. They’ve already got me for $488 a month, so their reluctance to shave $110 in premium from their bottom line is understandable.

They’ve dragged my application into its third month – even though I’ve been their customer for 5 years. I think being 53 years old is working against me big-time.

When I called Anthem this week, they hadn’t yet bothered to request the freckle record. So I called the doctor’s office myself and got it faxed to Anthem in about 2 hours. When I explained the logjam to the doctor’s assistant, she said, “Yeah, that sounds like Anthem.”

My agent says insurance companies typically make customers scrounge up records, which the underwriters then try to use against them to deny coverage or jack up the rate.

Yesterday I called Anthem to make sure they received the freckle fax. The Anthem rep said, “Let me check. Sometimes it takes 24 hours.”

Twenty-four hours to receive a FAX? What do they use, tin cans and string?

But they had it. Then she said, “It’ll take 7-10 days for Underwriting to review it. Call back next week.”

Anthem obviously doesn’t realize that their abysmal, we-don’t-give-a-damn attitude just fuels my support for HR 676, the universal healthcare bill that’s been sitting untouched in Congress since February 2005.

Anyone who thinks healthcare today is just ducky, or that its problems can be solved by relying more on these arrogant, inefficient insurers, obviously has employer-paid coverage and has never been mired in the bottomless bureaucracy.

Clinton, Obama, and McCain, the solution has nothing to do with making more people buy insurance, or making it more affordable (“affordable” by whose definition?). The answer is HR 676, which mandates a single payer system that eliminates the role of insurance companies.

We should all be able to focus on getting the best medical care, not spinning our wheels on useless paperwork just to keep obstructionist insurance clerks in jobs.

Pokey Health Insurer Revealed

March 3, 2008

By Karen

Another week has passed since I thought I overcame the last hurdle in getting cheaper health coverage through my insurer, bringing my wait to 2 full months, only to find out today that they’ve done NOTHING to get information they persist in wanting from my physician. Apparently, my word and a solid year without follow-up visits on my record aren’t enough to convince them that I don’t have a cancerous mole on my See-You-Next-Tuesday.

In fact, they suggested I call the doctor’s office myself and ask her to voluntarily send the information.

So now I’m an unpaid volunteer for Underwriting.

I’ve had enough, and I’m ready to name names. The insurer outrageously jerking around this loyal customer – who’s already been with them 5 years with no major claims – is Anthem.

A cheerful, helpful Anthem representative I just spoke to suggested I go ahead and pay April’s premium if March drags on and they still give me no answer. But they’re willing to back-date my new coverage to February 1 so I can recoup the $110/month price difference. The money will come in handy when they’re sticking me with a larger share of my out-of-pocket expenses under my new, lousier coverage – if I ever get it.

I just thank my lucky stars I’m healthy. If I really needed insurance for crucial medical care right now, Anthem’s proven that bureaucracy comes first and I could drop dead for all they care.

But when it comes to health insurers, I guess we all already knew that.

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