Thursday, August 16, 2012

Hi. My name is Jo, and I am totally demoralized.

Or not. It's been a rough week.

I talked to the friendly folks at the employee benefits office on Tuesday about the Ongoing Drama Of The Obturator. (For those of you coming in late, the prosthetic I wear to replace my palate/protect my airway/allow me to eat, drink and talk was not paid for by insurance. Given that the whole process cost as much as a new car [Hyundai, not Mercedes], I was a little peeved by that, especially given that the insurance company [Blue Cross/Blue Shield of Texas] first denied that it was medically necessary, then failed to follow their own rules on covering prosthetics.)

So I appealed, all the way to the Office of Employee Benefits. Beloved Sister and I worked up and sent a multi-page appeal letter complete with charts, diagrams, copies of reciepts, photographs of my mouth post-Harrowing, and ninety other things. The nice folks from the OEB asked me to send them a couple of additional pieces of paperwork, which I did. . .and I waited. They told me the whole kit and kaboodle had gone to some doctor who reviews things like this for them, so I waited.

And waited. I had no idea how long it would take for said doctor, who probably has a desk full of appeals, to get his head around mine.

So, when I called on Tuesday, I was expecting that things might not be fresh in the OEB's hivemind, given that the submission date for my appeal was back in March. I was not expecting them to tell me that the case had been closed for lack of documentation.

Well, to be more exact, first they told me that there wasn't anything there. Then they told me that yes, they'd found the file, but it'd been closed for lack of documentation.

Now: given the eight-page letter (with charts, diagrams, and circles and Xes on the back) and the two times I faxed the same information to my contact at the OEB, this was not what I was expecting. The nice contact at the OEB told me it would take her a couple of days to get everything together (right after she told me that everything was printed out and gathered up) for her boss to look at, so he could decide what was going on. So I told her I'd be calling her first thing Friday morning.

I am, to be nice about it, gob-fucking-smacked at this whole thing. I mean, I understand if they deny the appeal. Even though BCBSTX claims to reimburse non-network providers of prosthetics at 60% of cost, and even though they claim to reimburse at standard market rates (manifestly untrue; they actually reimburse less than Medicare or any other provider), I can see that they could finagle a way to deny my claim. That is, after all, their business.

Let me be a little more clear for you: The purpose of an insurance company is not to leverage your premiums into providing efficient, quality care for you. The purpose of an insurance company is to make money for their shareholders.

However, going back to the OEB: the University of Texas is a huge system, with many, many employees. The Office of Employee Benefits is, by necessity, the sort of bureaucracy that can handle that volume of employees. You would think that they could, at some point, have sent me a letter--not a certified letter or a wax-sealed scroll via elephant, just a letter--to tell me that they'd closed my file because I hadn't submitted some document or another.

Or, alternatively, they could've contacted me at the address, two telephone numbers, or email address that they had to let me know they needed more paperwork.

But they didn't.

Somewhere, somebody fucked up. I intend to find out who it was, and make them figure out how to fix it.

At first I was coldly enraged. I told Beloved Sis that the noise she was hearing was the sound of the bolts that hold Hell down shearing loose. Then I spent two days feeling horribly sick and depressed and stressed out. It's amazing how canalized anxiety becomes in the body.

Now I'm just peevish and determined.

Peevish. And determined. Very determined.


messymimi said...

Hold on to that determination, and if you feel any slack, the vibes of them you will feel coming from elsewhere will be emanating from me.

painting with fire said...

Years ago I was fighting to get coverage for the second surgeon on emergency surgery I had had. My doctor said that if the insurance company was playing games I should threaten (and then go) to the state insurance commission and accuse them of acting not in good faith. I totally fail to see how your obturator could be considered "not medically necessary" so if they play games push it up the ladder! Good luck - this muust be beyond annoying!

Red Stethoscope said...

Ugh! I'm so so sorry. Since starting med. school (oh, the irony), I've had to battle with insurance companies constantly. I have Aetna, also through a university health system, that blatantly denies claims that are coming from their own providers and should clearly be covered by my policy. I don't know how many thousands I've paid out of pocket for things like a routine annual gyn visit or follow-up sinusitis appointment. I started dating a lawyer last fall and since then, he usually calls and handles things. However, WTF kind of world do we live in that a lawyer has to call to haggle an insurance company into paying for routine office visits that are COVERED BY THE PLAN?

Anyway, this is all to say to please keep fighting because you and I both know that their arguments are BS. It seems like you just have to have enough muscle and gall and they'll do what they're supposed to do.

Mama D said...

Peevish and determined is good. No demoralization allowed!! You have fought through so much worse than this...I can't see you being defeated by paperwork and incompetence. This fellow Dorothy Sayers fan is sending good luck and bureaucracy-crushing vibes... ;)

Anne said...

I hope that you can hang onto that determination.
I wonder about showing up and offering to open your mouth and ask them to explain how it isn't necessary.
I also wonder about going to the newspapers.
I also wonder about finding a lawyer who will take it on contingency.
Best wishes.

Unknown said...

Give them hell, Jo. And when they are begging for mercy, give them some more hell.

Anonymous said...

Before I moved to Canada because I would have self-administered transcortical lead therapy if I had to keep trying and trying and failing and trying to help patients with this stupid bs, I too recommended the the insurance commissioner trick.

For veterans, either within or outside the VA system, a call to a congressional representative works well, too.

Since you're a hospital employee, this is also a very good time to pull in any favors you have with the big high corporate muckity-mucks- if you ever took care of some VP's beloved dying grannie, a call from that VP's office will fix this problem, and most likely ensure that the "independent" review falls in your favor.

Unknown said...

i think you may need to go to an ombudsperson or CEO or your local newspaper/consumer reporter if this doesn't work!

bobbie said...

Grrrrrrr ~

You go get 'em, girl!!!

Geosomin said...

Do it. I recently almost had my MSc defense rescheduled (at great cost to me) because a few forms got passed around the grad office by people on holidays who were "too busy". Luckily my supervisor went to bat for me.
These are basic things that you pay your premiums for. The common discourtesy of even an email is rediculous. Don't let them pass you over without a fight.