Pinky Pie

Insurance, bake sales & Me

Posted on: February 13, 2010

Insurance, bake sales & Me

Two days ago I ran into the director of St. Clare Health Mission, the free clinic where I have volunteered for years. I told her I was ready to volunteer again.

This clinic is for people caught in between – they don’t have health insurance and don’t qualify for private insurance. It serves the working poor who struggle every day to get by and come to the clinic when they often are quite ill. I’m glad to help with my meager receptionist skills.

I had been feeling great; but opening the mail took care of that.

Here’s the irony: I am  a free clinic volunteer with health insurance who could go belly up financially because of how much the insurance company will not pay – at least without a fight.

Friday alone I received three denial notices from my old insurance company – the old one that was supposed to be better than our current company. The denials totaled $6,042.45.

I can’t wait for today’s mail.

The “explanation of benefits” said:

“These are noncovered services because this is not deemed a ‘medical necessity by the payer.’ Experimental or investigational treatment or service is not covered.” That was for an x-ray service on August 31, 2009, for $669.25. X-ray service is experimental?

“We’re denying charges on this claim as we haven’t received the information requested from the provider. No further action can be taken on this claim until this is received.” This is for “medical services and RX Drugs” totaling $2912.50 on November 30, 2009. I assume it was for chemotherapy.

[The claim of not receiving information is common from this insurance company and many others. It is a ploy to make patients and hospitals to go through more hoops, hoping we’ll just give up so they don’t have to pay.]

  1. Same reason as number one. “These are noncovered services because this is not deemed a ‘medical necessity by the payer.’ Experimental or investigational treatment or service is not covered.” This time it was for “Hospital Charges” from August 31, 2009. No indication of what they were.

“We are denying this claim” is insurance-speak for “Have a nice day.”

I’ve written it before and will write it again. If you want to know who is at risk for medical bankruptcy, just look in the mirror or open mail from your insurance company.  Everyone is at risk. Everyone. Including me.

In addition to those charges, there are others the company has rejected. Supposedly, prior authorization is not required for every charge and boy do they mount up with cancer. You just get what your doctor orders for you and you have no idea what the costs are.

I received these shots to boost my immune system after reach chemotherapy treatment and the insurance company is not interested in paying them. Who knew they would cost something like $4500 each. And I received eight of them plus two others of similar costs to boost my red cells when I was severely anemic because of treatment.

Conceivably there could be tens and tens of thousands of costs not paid because of whatever excuse the company chooses to give. And it’s not even the insurance company’s money – the plan is self insured by my husband’s employer. The insurance company is merely the administrator.

On the bright side, I did not get sick and was not hospitalized during my treatments – that certainly saved money.

Some friends want to throw a benefit for me to help me with my medical bills. We never had one when our son had leukemia, but then insurance coverage was much better, although a year and a half after Matt died we got another bill, this time for some specialized testing for the hospital’s OB/GYN clinic.

A year ago, I was part of the planning out at a benefit for a very good friend who had weathered a very serious aneurysm.

It is a very odd feeling to think that I could be the subject of such a benefit, something she felt as well. I much prefer helping others. It is insane to think that I might have to pay medical bills with bake sales. But please preheat your oven. The good news is we know plenty of musicians willing to play – including my husband’s band, which volunteered its time at that benefit a year ago (and at other benefits).

At the most we are all one diagnosis away from financial ruin – and that is true for those of us who are employed and have insurance. We need universal health care and we need it now. To all of you who worry about the government getting between you and your doctor, I say there is no room with the insurance company between you and your doctor now. Insurance companies make life and death decisions based on profits.

Have you heard this one?

And they all lived happily ever after knowing they were covered by private insurance.

Clearly, that fairy tale did not take place in the United States.


3 Responses to "Insurance, bake sales & Me"

Sue, I’m so with you on this. What can we do? We in DC don’t even have a vote in Congress!

Sue – you are so right – I see it every day in the small world of “Dental insurance” – without seeing a person, or their records, an insurance company decides on what is “necessary” or “acceptable” – what a load of crap –

I am so with you – please any one reading Sue’s blog – email your representatives , this is important & necessary

We are all – one diagnosis away from financial ruin –

what can we do? what can we do? with the Republicans fighting us every step of the way….
I’d be happy to bake for you if you think it won’t get stale on the trip to Wisconsin.

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