Thursday, December 23, 2010

An Open Letter To Blue Cross/Blue Shield of Texas

Dear BCBS-TX Federal Employees Insurance Program,

You suck.

You suck like my vacuum cleaner sucks after I put a new bag into it. You suck like Austin traffic on a hot July afternoon with a thunderstorm on the way. You suck so much that nothing, not even light, can escape the event horizon of your awful fucking suckitude.

You told Rosie up at the Magic Prosthetist Elf's that you wouldn't cover but about a grand of the cost of my oral prosthetic. That's less, BCBS-TX, than Medicare covers on the same sort of prosthetic. You are actually reimbursing *less than Medicare* for something that allows me to eat, talk, and breathe properly.

Oh, but I'm getting ahead of myself. Let me explain what an oral prosthetic is, why I need it, and thus, why you suck so much.

See, I had cancer. I had a weird rare form of cancer that necessitated removal of half my hard palate and all of my soft palate. Open your mouth, BCBS-TX, and look at the back of your throat. That, on me? Is gone. It was that or lose half my face when the cancer that I had came back again and again because it hadn't been cleared out properly the first time.

Without a soft palate, I cannot speak intelligibly. I can't swallow very well, and spit tends to drip out of my nose if I bend over. Of the three problems, speech is the biggest one, and the one that the prosthetic I use helps most with. Basically, without the prosthetic, I would be unable to work, unable to function in public, and unable to communicate using devices like a telephone. I would be as handicapped as a person with only one leg or one arm. My disability would be huge.

There are two prosthodontists in the state who would take me on. Two. Both of them are non-contract (ie, out of network) with you. The guy I'm seeing now is the only guy around who's willing to do what it takes to get me speaking well. Yet you, BCBS-TX, think that I should drive four hours to some dude at MD Anderson in Houston who, by his own admission, is not as competent at this sort of extreme prosthodonty as my Happy Elf Doc. There is a reason that my surgeon sent me to Happy Elf Doc rather than somebody who also works for the University of Texas system, guys: it's because Happy Elf Doc is much, much better.

Anyway, I've got my first prosthetic from this guy, and because you only reimbursed a grand of its cost, he took only cost from me. The thing cost six grand for him to make, and I paid him five grand yesterday. He gave it to me for cost. He did not charge me for the fourteen hours of office visits I've already racked up with him. That's fourteen hours of face-to-face time with a specialist--time that he could've used to see two less complex patients.

BCBS-TX, I will need two more prosthetics before things are done here. I'll also need various adjustments and remoldings throughout the life of the prosthetic. If something goes terribly wrong and I break the thing or run over it with the above-mentioned ultra-strong vacuum, I'll need a replacement. Each of the two prosthetics I know I'll need will cost me six grand, just as this one cost six grand.

Simply put, BCBS-TX, my prosthetics will cost more than the total out-of-pocket-cost of my surgery, hospitalization, and preliminary MRI/CT/PET scan. And you want me to bear that cost without whining.

Well, guys, you're in for a very, very long year. See, it seems to me that if somebody had a limb amputation and the only folks who could deal with the prosthetic for that amputation were in Outer Backobeyondistan, you'd allow for that prosthetist and his minions to be in-network, just that once. You would reimburse fair market value for that prosthetist's labor, especially if it were considered a really unusual case. You'd be, in other words, something other than the black-hearted, asinine, no-explanation-of-denial dipwads you're currently being.

My mouth is bigger than it was before surgery, y'all. You may be BCBS-TX, but I am a pissed off woman who has already had the shit scared out of her. I'm gonna bug you until you pay up.

In fact, I'll bug you so much that you'll pile cash on the table in front of me until I smile, then give me more just to go away. You've thrown down this gauntlet, BCBS, and I am *pissed*.



Silliyak said...

I think you should use references that they could understand. ( I'm assuming they are mostly men) Have them imagine they have testicle cancer which, untreated will spread to "What's left", and cannot perform without prosthesis'. They get 1/8th of a testicle replaced just as a reminder of what used to be. Anyway, you get the drift, I'm sure you'll come up with something better.

Jenn Jilks said...

You go. That is ridiculous.

Anonymous said...

It is absolutely ridiculous that you should have to pay AT ALL for a prosthesis. Full stop. This is not a tit job or a face lift, this was surgery to save your life, and the tools to enable that life afterward. There should be no need whatsoever to justify the need to eat, swallow and speak.

I have no idea if the Canadian health care system, flaws and all, would cover this but if it didn't I'd be all over my health minister, federaland provincial. Like eating and swallowing and speaking are optional...

The very best of luck in your pursuit of justice. God help the poor bahstahd who doesn't have 5 to 10 K laying around...

Barb R.

Anonymous said...


Hi. I am an RN, CCM...this is my day job for Another Giant Insurer.

Ask your surgeon guy (assuming he is IN network with BCBS) to write a letter requesting a clinical gap exception...basically saying that the sort of prosthesis you need for the sort of cancer you had is requires clinical expertise not available in network. Ask the surgeon to include all the gory detail about his handiwork and all the deficits you would have without said prosthesis. Then write a letter of appeal. Be sure your letter includes the magic word "appeal". Even though they still have time to be gracious and step up, assume that they will not be so inclined and CC the appeal letter to your state dept. of insurance.

And, you are right, not having a prosthesis can certainly affect things like employability. I have worked with a patient who is a respiratory therapist, whose hearing was damaged by head/neck cancer radiation. Her state dept of vocational rehab paid for her hearing aides so she could return to work because her lame-o insurance would not.

I wish you luck.

Anonymous said...

Fucking Insurance Companies. Blue Cross Blue Shield, what the HELL is wrong with you ?. Go get them Jo !

Lynda Halliger Otvos (Lynda M O) said...

o, I am appalled, pissed off and too poor to send you any gelt til after the first. Who do they think they are and why would they reimburse so poorly? Cuz whatever they deny goes into their salaries. Bastards.

Anonymous said...

Don't let 'em beat you! This is a more necessary prosthesis than a leg or an arm. How dare they take money and then turn down patients who need equipment to help with their care. Far as I'm concerned, all insurance companies need to be abolished and we need to go to a national care system like civilized countries have. And while I'm on the subject what sense does it make to tie the existing healthcare to places of employment? Situations like yours make me angry. It's not fair but they think they have us over a barrel.

Anonymous said...

I suspect a lot of rejections are automatic, and you have to appeal the denial, citing that there aren't any in-network guys in Texas to do the work, it is a medical necessity, etc. Probably have to get your oncologist to write a letter of support. Maybe cite similar cases if you can find them, that were appealed and approved. You have a strong case, and might be stronger if a lawyer (or law student?) helped write the appeal so it is non-emotional and very fact-specific.

When my son's ins. co turned down his lung transplant, his sister (a lawyer) researched cases in nearby states, pending legislation in our state, the risk of public outcry if denied after appeal....and got approval for him very quickly.

You can also get the state insurance commissioner involved in this. And the people at your hospital/employer who negotiate insurance purchases.

This is clearly wrong and needs to be fixed.

Loz said...

The more I hear about your system in the States the more grateful I am for ours in Australia.

Anonymous said...

I could never understand why they don't cover EPIPENS for God's sake. I know they are only $100 each, but when you need two and are poor that is a lot out of pocket. I guess they think the allergic should just die of anaphylaxis.

Anonymous said...

Yes, appeal.
This is just another reason why we need to be able to buy health insurance across state lines. Your insurance firm needs competition.

RehabNurse said...

You go, jo!

And I believe RN, CCM is absolutely right. Appeal is a magic work in so many places.

And another tip, for all of you out there in the great wide world, if you have any patients who are US military veterans, call up your local VA.

The US Gobermint has loads of resources and even if they screw up getting them, patients you will eventually get back pay if someone will make your case.

As Winston Churchill said, never, never, never give up. It's so true.

Cr0w$C@lling said...

Anon @ 200 seemed to have a really good idea. However, if that dosen't work please put the donate button back up and label it legal fees.

I will have your back bitch.

May I please wear blue face paint to the hearings????

Fight on!


Anonymous said...

Our insurance allows us to go out of network, if they do not have an in-network provider within 30 miles. They may, however, pay "usual and customary".

Like everyone else says, appeal it.


messymimi said...

I'm on your side all the way on this one.

Anonymous said...

You might want to ask Happy Elf Doc why he isn't part of the network.

When I switched insurance from Aetna to Coventry because I was retiring and Coventry Medicare Advantage was cheaper, I found out that my doctor wasn't in network - she didn't want to deal with Coventry.

That said, I agree with what you have said about bitching until you get some relief, and I think having your surgeon send a letter is a good idea.

clairesmum said...

yup, a lot of these are automatic denials the first time around, and the suggestion of the first anonymous (who works for a big insurance co and outlined how to appeal) sounds absolutely right. Keep the contacts with BCBS as rational and logical and NON emotional as you can. One of the unspoken strategies in those places is to piss you off so you go away, or so they can label you 'a nutter' and stop listening to you. Vent the emotions elsewhere (like here) and proceed with the appeal. sounds like you are gonna have to deal with BCBSTX for a while...
sucks, doesn't it??!!

wv "foocked" - how funny is that!

moplans said...

GRRR you should not have to deal with this.
So glad Dr Elf has been so helpful and wishing you strength for the fight w these asshats

Kaye said...

and don't forget to go to your congressman/woman if all else fails - or the state insurance commissioner

gorochan said...

I also hate BC, one we often deal with is 'tru blue' brand and they never want to cover anything, even after hours of discussion of patient needs and safety. It takes so much to get them to do what is right.

Anonymous said...

Got a hungry consumer advocate reporter in your area? "Nurse denied necessary care" sounds like the kind of story they'd be itching to get.

Unknown said...

Ridiculous. Absolutely ridiculous.

One thing these companies hate is bad press. You think you're willing to contact a news station or paper and tell them your story?

Unknown said...

I've been lurking around your blog for a while, but this post finally drew me out of hiding. I also have BCBS Federal, through my mother, only we are in Minnesota. I was born with Ehlers-Danlos Syndrome, but wasn't diagnosed until I was 16. Since then I've needed several surgeries to correct various issues (short lower jaw, twisted tibias, and flat feet) and BCBS has decided on various occasions that they didn't need to pay the specialists, who are giving me the ability to hopefully live my life with the use of certain joints for at least a few more years, the full cost of care. My medical bills alone have been several hundred thousand dollars, and my family has had to negotiate with several hospitals on making payments, and making the minimum possible.

I hope that you give BCBS hell for trying to take away your ability to live close to a normal life. You've been through so much, you do not need this! If you have to, take it to the local news, I'm sure they'd love to hear your story. Good luck, and I hope you continue to take the world head on.

Celeste said...

Sounds like you got some great advice about how to appeal and how to turn up the heat. If those don't work, I'm behind you all the way for going to the TV stations. I think you can also send a letter to your state's Attorney General. This seems like a fraudulent practice.

Anonymous said...

Appalling. Rise up and smite them mightily!
--Queen Anne's Lace

Anonymous said...

I am also a nurse working for an insurance company - check your policy for distance limitations - some policies have req that par physician has to be within 50 miles of yr home otherwise they have to let you go to non par physician and cover it as par. Also as the prev ins co. nurse said - request waiver for them to bill non par as par provider due to circumstances - if you can ask for a nurse or case manager at yr ins co to assist you with this it usually goes smoother... Also write an appeal letter as she said. READ your policy to see what EXACTLY it says about prosthesis coverage. Also let HR/benefit person @ work know whats going on...

woolywoman said...

God, I love my insurance (Kaiser Permanente) They pay for my H*umira, which is in the thousands of bucks, but without which I could not work. They have paid for everything by whack job immune system has needed.

I am still being sent to collections for crap Blue Cross was supposed to pay, didn't pay, and I ended up on hook for it.

I agree that all of the expenses are automatically refused. like the idea of CCing the state insurance commissioners, and getting Dr Crane involved in the appeal. Rock on.

Penny Mitchell said...

Perhaps it's the dilaudid, perhaps it's the rage. Perhaps it's both.

No, actually, it's just the rage. The rage is overshadowing everything else.

My only impulse at the moment is to beat these people bloody, and I don't meant theoretically.

jb said...

Who amongst us has the courage to cancel their insurance policy? We are all enabling the continued ability of Insurance Companies to benefit (and profit from illness, calamity, death, misfortune.)
Time to wake up my fellow victims. Cancel your insurance policies today. Period. End of story.
Perhaps if this happened they would get real and stop inserting small print.. stop forcing enrollees to use "in network services" stop telling the Dr. what drugs they can and cannot prescribe. Stop limiting payments for necessary services for all medical diseases. What is happening now.. is nothing more than legalized extortion. How sad that the masses have been traumatized enough to feel that paying someone to protect them( for future maybes that haven't come into existance in the present and to buy into these policies that will not cover them in the future) has become a mainstay of Americas bad habits. Drs., Hospitals, patients.. are all being held hostage by Insurance companies that are taking a pertentage of every dollar spent in this country for the well being of it citizens. The fear they prey on (and are complicit in instilling) is the best marketing tool every devised. Who amongst us would be will to say.. NO MORE!
Wake up... Wake Up! stop funding this insanity. STOP NOW! There is nothing stronger than the will of the masses.
It matters not how many affiliating companies BCBS split their corporation into... it's the same parent!!!
and then call the president and your congress.. tell them too.... you want the same coverage they have. PERIOD... PERIOD.. PERIOD

Elyse said...

Assholes. Their game will be to wear you down slowly and bide their time with obstacles, procedures and hoops in a cold and chilling way - armed with the knowledge that most people tire and drop away - kind of like staring down a beady-eyed reptile. If it gets discouraging we'll just give you your prn shot of "you go girl"!!!

jwg said...

This should be fun! Go get 'em. One piece of advice. Get receipts for everything you mail them. Keep copies of emails etc.. They'll try and get you on a technicality.

Anonymous said...

Okay so you say they won't pay but what you really mean is they won't pay what the doc. charged. They did not denie him in network status, he chose to be out if network. There is a usual and customary rate for his services that they did pay but he refused to accept and decided to bill you for the balance.