Monday, November 14, 2011

Dear Blue Cross and Blue Shield of Texas,

You have pissed off the wrong fat bitch.

I was moderately pissed off before now, when I discovered that you reimburse my prosthodontist one-hundred and fifteen percent of Medicare reimbursement, or approximately a thousand bucks for each prosthetic. You don't allow appeals, and you've ignored letters from my surgeon and the prosthodontist.

Now I'm *really* pissed, because this is what I found out today:

The lowest reimbursement for an oral prosthetic offered by any of the insurance companies with which Dr. Elf deals is fifty percent.

BCBS in other states covers between 60% and 90% of prosthetic costs. Even BCBS Oklahoma.

BCBS Texas covers close to all of the cost for limb prostheses.

BCBS TX, you are in deep, deep shit. See, when all this started, with me running up bills that I will never, ever be able to pay off (even at the competitive rates offered by the pleasant people at the credit card company, when they found out all these charges were for medical expenses), I was determined to blow into your offices like a bulldozer and make something change. If it didn't change for me, I reasoned, I could change it for the next poor bastard who lost part of a palate to cancer.

Now, a year on, I've lost energy for the bulldozer approach. Instead, I've decided to take the poppy-seed-under-the-prosthetic approach. A poppy seed doesn't do much, at first, but then it becomes annoying. As it digs into the mucosa left behind by a palatectomy, it gets painful. After a few hours, you're dealing with outright pain, runny eyes, a swollen set of sinuses, and--worst of all--the tissue around the poppy seed has become irritated enough that you have to use commando tactics to get it dislodged.

My finding out about differing reimbursement rates coincided with your sending me the same polite form letter you sent me a year ago: "Since we have not been successful in reaching you by phone" (even though the first letter had my diagnosis, Subtotal Palatectomy, right there in the header) "we invite you to call us to help us resolve any issues you have in your care. . . ."

Oh, Blue Cross, *never* ask me what you can do to make my life better. I'll tell you. I'll give you printouts, even, with diagrams and charts with circles and X-es on the back.

Strangely, darling BCBSTX, something very interesting has started to happen in the media, as well: Bigton's local paper has started doing an expose series on practices within Giganto Research and Development's operations. This follows a comparable expose done by Local Paper's sister paper north of here. Given that Giganto Inc owns Sunnydale, and that Giganto is the subscriber to your insurance, and that I am a paying member of BCBSTX's insurance pool, wouldn't it be interesting to have things like your reimbursement rates made public? I mean, things like oral prosthetics aren't even covered in your brochures' fine print. It might be nice, what with oral cancer rates on the rise, for the general public to know exactly what you cover and what it means for the people who pay for your service if you don't cover something they need.

Don't get me wrong, Blue Cross: I'm grateful that you covered the majority of the cost of my surgeries and follow-up. Without you, I'd be declaring bankruptcy. Still, it seems a little unfair that you'd cover the prosthetics necessary for a person to, say, walk, yet not cover the prosthetics necessary for her to maintain her own airway. If I needed an AFO or a hook-hand, you'd be at the plate. Now that I need something that lets me talk and not choke when I drink, you're bowing out.

And that sucks. More specifically, it's sucks for you. I may not be able to keep bulldozing, but I can sustain the level of annoyance required to feel like a poppy seed forever.

It is ON, bitches.

16 comments:

Donna said...

Sometimes Blog power makes huge companies rethink their policies when you mention them on your blog. It has happened to me. I seriously hope it works for you also. At least some of us will decide to steer clear of BCBS.

clairesmum said...

I'm confused - does BSBS pay Dr Elf (the prosthodontist, right) to MAKE the prosthetic, but does not actually pay for the item that he creates? I can see an insurern thinking that was a logical decision....am I reading you correctly?
The whole coverage for prosthetics of any type stinks, and doG forbid you need a repair!
being a persistent poppy seed - another hat to wear!

messymimi said...

Merciful sakes.

Don't get me started, this makes my blood boil for you, and since i was raised to be polite or silent, i won't say what i'm really thinking.

Keep poppy seeding them to death.

shrimplate said...

Drop me a line if me or perhaps some mad-hacker psycho with powerful computer kung-fu can be of any assistance.

I'm not suggesting anything unscrupulous. It's just that I know a lot of people whose names end with vowels and they like to; you know, do things. To other people. It's not everyone's cup of tea, but these gentlemen seem to enjoy their work.

bobbie said...

You GO, you little poppy-seed!!!
Irritate them to HELL!!!

bdaiss said...

You go girl. And let us know what we can do to help. I'm with those who think both insurance coverage and tax codes need to be majorly simplified. Making it confusing as all get out just to screw the little guy is Not.Fair.

Silliyak said...

Do you a media "Consumer assistance" person on any of your local TV stations? They seem to have a lot of influence. They could at least embarrass the HMO.

Penny Mitchell said...

"I mean, things like oral prosthetics aren't even covered in your brochures' fine print."

Their brochure, or the policy you signed? I'd love to know what the policy you signed says about oral prosthetics. Surely it says something. Surely they can't make this shit up as they go, can they?

Rosanna said...

'Just a thought: would your contacting the OralCancerFoundation.org possibly be helpful? (During a Google Search, when I read, "The Oral Cancer Foundation Combines G.u.e.r.i.l.l.a. Marketing With Tech Savvy for Public Good," for *some reason*, I thought of *you*, Jo, haha!!)

Also, now that you ARE a Nationally-Known Author in Reader's Digest----(and, by the way, "Secrets" #6 and #47 ROCK!!)----we all know that you absolutely won't "use" your new-found fame unless you really need to, i.e., unless you REALLY *N.E.E.D.* TO (for a greater cause)............ like now.

Obvious, damaging inequities, (e.g., like this one with TX's BCBS), genuinely make me ACHE inside; so I'll just say............ *G.O.* ~ *G.E.T.* ~ *'E.M.*, ~ Jo!!

Knot Telling said...

I suggest a blog-based campaign to start. Bloggers will link to this post (or some other you might write for the occasion) from their own blogs, inviting their readers to do the same.

Excuse me now, while I dust off picket sign painting kit from my student days...

Just My 2¢ said...

Ya know...
I've been amazed at the ability of Twitter to make companies stand up and pay attention to adverse publicity. For example, the New York fireman that was denied medical benefits for injuries received on 9/11.

Consumerist.com is also surprisingly effective in getting the attention of corporations.

Laura said...

*makes popcorn, pulls up chair*

If they didn't have it coming in spades, I'd almost feel sorry for BCBSTX. This is going to be fun to watch...keep us posted!

beth said...

I may be wrong, but it sounds like the insurance company thinks you went to the oral surgeon for cosmetic reasons. They took you and oral surgeons letters of appeals and put it in the denial bin, because they figure you went for braces. They never looked at your appeal, twice, three times, and let's the surgeons not get paid, but you still owe BCBS, because you need them. INSURANCE COMPANIES DO NOT SET THE STANDARDS OF PRACTICE! Be the bull and don't give up, and don't pay. They will lose, but they are hoping you will just give up. I am now on pregnancy Medicaid, because no insurance company would take me because it was a pre- existing condition... REALLY? now I am limited on how much I can earn because being on Medicaid you can't make touch money.. what kind of .message does this send? Ps. So far pregnancy Medicaid has great benefits... I just don't get it.. good luck! I'm sorry you are dealing with this.

Anonymous said...

sorry, but it's not that bcbs of tx doesnt cover your prosthesis, it's that your employer group chose to not purchase that section of care when buying the plan. And or that if this section was part of the plan purchased, it is considered not medically necessary. All "plans" are not equal. the employer group has the power to change the provisions, limitations and coverage amounts of the plan when it is purchased.

joykenn said...

OK, this is totally ridiculous! Is there a state insurance board in Texas? If so, protest that oral prosthesis for cancer patients and people with palate deformities are not fully covered.

Write a letter with a copy to the head of BCBS of TX. Write a letter to Big Town's newspaper. Maybe about the poor plan that Giganto Corp which owns Sunnydale provides you with. Complain about unfair treatment for cancer patients with oral cancer whereas other prosthesis are covered better. Explain folks fall down with only one leg but you can't talk or breathe well or eat or drink without the prosthesis.

Remind them of people without the means to pay the rest of the bill--at least you have credit cards. Beat the drum. Send letters to Tx legislators. Send letters to everyone you know. Start a Facebook page like the woman did you got angry about Bank of America fees. You're an excellent writer, use that skill. Good luck.

Anonymous said...

Medical policies are located online. I am not sure of the name of your group so there is always the possibility that the group does not cover this item, but as long as it is not cosmetic it is normally legally required for insurance companies to cover the needs for any device to allow you to regain your daily life functions. NEVER let them tell you that you do not have the right to appeal. You have the right to a 1st appeal, a 2nd appeal if the 1st is denied, and then grievance rights which means that you are allowed to appeal again and then it is reviewed normally by the board of directors. If they do not listen the way you think they should then inform them of your intent to involve the state legislator and the Texas Department of Insurance. I have attached links for the policies involving oral prosthetic devices and the TDI website's contact information. I hope everything works out the way it should and I just want to say that the work nurses do is hard enough every day without you having to worry about the insurance company who is supposed to be there for you leaving you in the dark. And to speak honestly the more people yell and scream and rant at the individual they are speaking to in customer service the less that person wants to do. Normally if you are nice to that person they are going to be more likely to help and some even go above and beyond. I do know that it is not everyone, but there are people who will care about your problem and they will do everything in their power to push for your care to be as problem free and cost efficient as possible. Good luck and I hope everything works much easier for you.

http://medicalpolicy.hcsc.net/medicalpolicy/home?ctype=POLICY&cat=DME&path=/templatedata/medpolicies/POLICY/data/DMEQUIPMENT/DME103.001_2011-08-15#hlink

http://www.tdi.texas.gov/webinfo/contactus.html