Friday, 12 October 2012

Insurance Rant

OK, I am a nurse case manager for an insurance company.  This is a double-edged sword FOR SURE.  This was never what I would have considered my "dream job", but it actually has come to be exactly that- because of my family.  It enables me to be close by, have a regular schedule, and get the boys to appointments all while making a good income.  And I love helping people, and I feel like I really do that- I work with organ transplant candidates and recipients, for a medicaid/medicare insurance plan. 

That is why I become all the more enraged when something I know should have been done, and should not have been difficult, slips through the cracks for my kids.  I got a call from Nate's OT today, at 4pm, stating that Nate has reached his 60th visit and that if I want him to be seen tomorrow I will have to pay out of pocket, as the insurance company has no record of him being granted extra sessions.  This, when I have a letter from the HR department of my husband's work stating that Nate has been granted these extra sessions for this year- enough to take him through December twice a week.  First of all, the health insurance company was not even given the "freedom" to make a medical determination as to whether these extra sessions were necessary.  No, it was fully a financial decision by the HR department, who then needed to contact our insurance and inform them of this change.  Somehow, this did not occur.  Grrrrrrrrr.......My issues with this situation are many- first of all, the insurance company has nurses and physicians whose sole job is to determine medical necessity of such changes.  So why weren't they entrusted to do this?  Why did it have to go through HR in the first place?  And why the break down in communication?  My husband and I certainly did our due diligence, he wrote a letter fully explaining the situation and was "granted" these sessions, but told that if we want Nate to be able to go next year, we will need to subscribe to the more expensive insurance plan.  It costs 3x as much.  Nice.  Not to mention that even with the plan we are on, they only allow 60 sessions a calendar year- and that is the number of sessions of OT, PT and speech combined.  So if I was taking Nate to speech as well, we would have run out of sessions when?  In May?  How is that reasonable?  I mean, I always joke that I paid five dollars for each of my children- clearly that is not accurate over all, but truthfully, I did pay one five dollar copay at my first OB appointment and that was it.  Pretty sure that cost the insurance company more than Nate's OT sessions- I didn't have a baby this year- I would like a transfer of funds, lol.  Just so frustrated with this.

And while I'm at it, let's just touch on the inequities of different insurance plans in general.  I find myself practically lunging at the T.V. during the debates this year- being in the trenches of administering both medicaid and medicare has changed my views on things so much.  Knowledge can be a scary and maddening thing.  I want to make clear before I continue- I am not criticizing medicaid and medicare for the benefits they provide.  I am criticizing private insurance.  Because, see, I KNOW what kind of benefits the medicaid and medicare recipients are afforded.  And I know the benefits that my family, who pays for their insurance, is afforded.  I know that my clients often receive sedan service to their medical appointments- not a bus pass, not an ambulance, SEDAN SERVICE. I know that if we approve a certain number of visits for a member and they end up needing more, the provider simply has to write a letter stating why this service is necessary and after review, the member can have the service.  I know that my medicaid recipients have little to no copays on medications.  And that if they by chance have a substantial work history and qualify for medicare on top of this (because of their hard work or severe medical condition), they actually wind up paying MORE for their medications.  Why?  Because medicare is not as comprehensive as medicaid, and many states, in an effort to cut the budget have decided that if medicaid (which is state run by the way, not federal) is the secondary insurance they will not cover the difference on prescriptions that are covered by medicare.  Medicare's copays are way more expensive than medicaid's.  Soooo..... I find responsible people who have qualified for medicare in addition to having low enough income to qualify for medicaid are being punished.  This is pretty common among my organ transplant patients- they work, they get sick, they can't work, they qualify for medicaid.  And then when they either hit a certain age, or begin dialysis they qualify for medicare.  Sounds great right?  Dual coverage?  Guess what- transplant meds, they're really really expensive.  If the medicare copay is a percentage- half of these patients can't afford their meds!  Seems like punishment to me.

Can you tell I am passionate about this?  I did what I never ever do to the insurance coordinator at Nate's OT- and I'm not proud of it.  However it served it's purpose.  I yelled.  I said "so what you're telling me is that I have to call HR and I have to call the insurance company and bring THEM together, which I'm pretty sure they should be able to accomplish on their own, or you won't see my son.  Oh, and you're telling me this at 4pm on FRIDAY?  When his next appointment is Saturday?"  I don't think so.  Our family is a goldmine to the therapy center- both boys go twice a week most of the time- I think they can work with us.  And she agreed eventually that if I sign a waiver stating that if the insurance refuses to cover the sessions I will be responsible that they will see Nate tomorrow.  You know, the state funds medicaid, and the federal government funds medicare- but when my patient needs something outside the "norm" I don't have to give them a buzz to get the needed care.  I just find this strange, that's all.  Also, to be clear, we love the boys' OT's.  They are wonderful to them, and the insurance coordinator has been great too- she is the one who notified us ahead of time that we were coming up on our "cap" in the first place.  So that we could get this modification in place.  So I feel bad for yelling- but I am glad that Nate will be going to his therapy appointment tomorrow. 

1 comment:

  1. I don't blame you at all. Sometimes venting keeps you sane. I do prefer if a parent is doing this to tell me ahead of time, though. That way I will concretely know that you are not mad at me, but at the system.