Monday, March 9, 2015

It pays to understand your medical insurance and be persistent


Life circumstances have forced me to have a really deep understanding of my health insurance coverage. That said, sometimes claims are done incorrectly, or there is missing communication from my health insurance provider. Recent concern has been the 5 of us returning to the opthamologist for our vision needs.

Kidlet number 2 went to MD # 1 back in July (we had to address all concerns prior to Sept 1, as we were in the fortunatae position of having met our deductible. $158 charge was dropped to in plan discount of $133.35 for which we paid $0. He then had to see MD #2 for a particular eye problem. $192 charge dropped to in plan discount of $166.36, we paid $0.

I went in Jan. $213 charge was declined by insurance as it was "routine." Communication with my health ins company advised me that if I had been there due to a medical concen/condition, it would have been paid at 100%. Since there was none, I was stuck. Knowing my medical history and recalling that this same MD forgot to code my diagnosis last time, I called the MD's office, explained that once again we are in the same situation, I have a permenant diagnosis, in addition to being near sighted, and if coded correctly, this should be covered @ 100%. Sure enough, it was resubmitted and the charge dropped to $133.36 which was paid in full, and a $55 balance for the refraction was sent to my secondary vision plan in CA-more on that later.

Kidlet number 1 went for a routine visit in Feb. $158 charge isn't covered but was sent to the secondary vision plan. I was told by the ins co. that this should mean $45 reimbursement. Whatever the final charges are, DD is responsible to pay them, which she is keenly aware of.

Kidlets 3 & 4 went also in Feb. Both of their claims were denied by plan # 1 (charges are $213 each) and forwarded to the secondary vision plan.

Fast forward, and kidlet # 3 needed new lenses for his glasses. We ordered those vs replacing the entire set of glasses. We got them last week, and he immediately noted that they aren't right. Very blurry in one eye. We returned to the optical shop affiliated with the practice, they confirm the RX is correct. Need to see the MD who prescribed  them. Long story short, I received a call that they could see him today or Wed afternoon. We went today, a new lens is being ordered, there will be no additional charge for us, the incorrect lens will be returned to the lens company for a credit to the MD. Since I had the MD in front of me, and he was discussing kidlet's medical issue, I told the MD that I had asked about this on going DX in Feb and was told by the MD that it was resolved. Turns out it is more complicated now but YES, it does still exist. They go to the computerized records, see what I wrote, OK, we can resubmit that. I anticipate that we are now off the hook for any charges, once this gets reprocesssed.

I asked also about kidlet # 3-same issue, why can't his claim also be looked into. Turns out that since the MD didn't do a particular test (that he did with kidlet # 4), and the last one he had done was back in 2009 with a different MD in the practice, he won't resubmit. Ok, now I know to mention these DX and to insist that they perform the test which consists of holding a weird yardstick gizmo in front of his face and seeing how the eyes work (or not) in unison. Fortunately, I have separate resources to cover this anticipated OOP expense, once all is said and we get the token payment (anticipate another $45) from vision plan 2.

The second vision plan and how this works was a total mystery. No where on the insurance website, our ins. consultant website, my contract does it mention this, nor how it works. Hmmm . . will be persuing that; I've already alerted our Union about this breach in communication. While I thought I was doing the right thing by asking, "Do you take X insurance?" and being told yes, in order to make an appointment, I did NOT know to ask, "Do you take X medical insurance and do you take X vision plan insurance?" Sigh.

I am considered the "go to" person where it comes to insurance issues. This latest surprise blindsided me. I am not completely giving up, however, and I strive to educate others as to this 2 tier vision insurance so that we can make informed decisions. Moving forward, the 3 of us with clearly identified, medical vision issues can continue to use our current opthamologists. Kidlet number 3 will go once more, BUT I will clarify, underline, what have you, that he has a vision DX. DD may* choose to go elsewhere, as she has only very mild RX glasses, which she rarely uses.

Total charges for the 5 of us are well over $1000. Luckily, when all is said and done, I will not pay anything.

So bottom line: 3 of us should be fully covered, possibly a 4th as well. One will pay whatever OOP charges are incurred, but should she go to a clearly in plan vision provider, there would be no charges. Something to consider.


saraband said...

The more I read about your complicated medical insurance issues, the more thankful I am for our UK National Health Service.

Theresa F said...

Insurance companies probably employ a whole department of people who draft new and increasingly confusing rules and regulations. One needs a PhD to decipher insurance forms.
One can only imagine how many people overpay on a daily basis because they cannot understand insurance jargon. It's criminal.

Baroness Prudent Spending said...

Kudos to you for digging in deep. I have found as the years have gone by and more costs are passed to the employees (from the employers) that using insurance and understanding all the rules has gotten much more difficult. And no I don't blame Obamacare. This has been happening long before that was enacted. I work in an industry which has traditionally had good benefits but each year they are whittled away little by little.

Sorry rant over. It's just so frustrating because you often feel like you are walking on a treadmill but not going anywhere. :-/

Marcia in rural WNY said...

My daughter is a big help on insurances as she used to work for the hospital and for private doctors. She has had annual changes in insurance for the past few years as her husband's employer kept changing for cheaper coverage. She knows to read every sentence they give her and sometimes even helps me with mine. I am lucky to have good insurance coverage from my former employer, and since I am now retired, information on some changes never make it to retirees unless someone "discovers" it in their own use of it. We have a retirees web site to exchange information (and gossip) on! It really helps a lot--someone usually knows the answer if we have questions. I worked in the medical field some too, so am aware of slightly more than most people. It's very complicated and often a matter of a wrong code that makes the difference between payment and no payment.