...Or You Could Pay $4,150.00 Out Of Pocket

Every new year I go through the same game of trying to get my leukemia medication.

The game goes something like this:

It's time for me to pick up my prescription---
     However, I am stalled because the insurance needs to re-approve it for the new year.
The insurance re-approves it (which usually takes a week or two)
     However, they only re-approve it for the first month
I pick up my medication
     However, I need to have my doctors fill out more forms and fax them in over the month so I can hopefully get my medication the next month without any hassle.

This year the game was changed up on me.

It's time for me to pick up my prescription---
     However, I am stalled because the insurance needs to re-aprove it for the new year.
The insurance re-approves it (which took about a week and a half) BUT ONLY IF I RECEIVE MY MEDICATION FROM THEIR MAIL IN SPECIALTY PHARMACY

"Okay, Fine." I think to myself

So I call the specialty pharmacy who tells me they do not have my prescription and need my doctor to re-fax in all of the information including my co-pay assistance card.

My doctor faxes in all the information, insurance/copay cards in on Wednesday of last week and I am assured by the new pharmacy that everything will be ready to go within 24 hours.

On Friday morning I call, because I haven't heard anything and I figure I better check in.

I speak to a woman who informs me my copay is $4,150.00.

I tell her my co-pay assistance card helps with that and she tells me they do not have my co-pay assistance card on file. Frantically I give her all the information over the phone and she tells me she has put an "emergency" note on the file to get this shipped out to me.

I hear nothing.

So Monday morning I call to check back and am told they have all the information in the system and to check back at 4pm (Pacific Time) to make sure the medication goes out tonight.

I call at 3:50pm (Pacific Time) and a new person tells me it will take another 7 Business days for them to "verify" my co-pay assistance--- OR I COULD JUST GIVE THEM $4,150.00 AND THEY WILL SHIP IT OUT TONIGHT


I hope each and every one of you has that kind of money laying around for one month's worth of medication--- but I'm guessing I'm not the only one who does not.

The only way to get any of my Daily Leukemia Drug for the month of January is to have them over-ride the system and allow my regular pharmacy to go ahead and fill the prescription.

I ask them to do this--- and they tell me they are only open for another half hour so I need to call my local pharmacist, have her try and run the prescription through the system, get a denial number, call them back with that denial number, and THEN they can release it to her so she can order the medication for me to receive before February 1st.

I hate to make assumptions--- but isn't it convenient that the insurance company doesn't have to pay anything for January if they can't have the drug approved until February?

My local pharmacy originally tried to re-fill the prescription on January 10th. The December prescription ran out on January 14th. Today is January 28th.

Anyone else see a problem here?

Health Insurance and Profits: Capitalism is not to blame

Today I read this article in the NY Times:

http://www.nytimes.com/2013/01/09/business/health-care-and-pursuit-of-profit-make-a-poor-mix.html?pagewanted=all

For those who read this blog and The Malformation of Health Care book http://www.amazon.com/dp/B009V37CXU  you already understand my position on what this article says (the author is preaching to the choir).

I find it fascinating that no matter how many discussions, articles, programs, books, take on this topic; these companies still have the audacity to continue acting in bad faith.

What will it take for incredibly high powered, well lobbied, excessively wealthy companies to become accountable for bad practices?

I'm sickened to say, probably "nothing".

Despite the claim that corporations are people, corporations (especially on this high of a financial level) do not have an internal moral compass. Most people who work for these companies are at the mercy of this corrupt system just as much as the customers who pay their premiums each month in hopes their policy will cover them should tragedy strike.

This is not capitalism. This is greed.

The reason I say this is because I know what the ideals of capitalism are, I grew up on them. My family owned a small hardware store for over 100 years. The reason the company lasted for 100 years was because of the pride taken in our services and products. We didn't force anyone to shop at our store, but we gained loyal customers, based on our integrity.

We offered competitive prices and guaranteed our products and our work. If a customer came in to the store and said a product was faulty and we didn't either exchange the product or fix the issue, we would have been run out of town. No customer would have shopped with us.

When a health insurance customer comes to the provider with a problem, many times they are ignored, avoided, or told of a previously undisclosed "loophole" that frees the insurance from all coverage obligation.

Capitalism only works when those servicing the population understand that first and foremost they are performing a service for the community. Profits come when that service is performed well. If that service is performed poorly, profits should be reflected.

That is capitalism.

That is not what is going on currently within our health insurance system.

Stalling Tactics To Avoid Appeal

Hi everyone!
     I hope you all are enjoying your holiday season. I know I have been doing my best to focus on family and friend gatherings and celebrations rather than typical daily life. However, I'm realizing that I can not simply stop working on important outstanding items so I'm rejoining the world today.

 It has been awhile since I've updated you about my insurance situation. When last I wrote, I spoke about ERISA and how the law is interpreted to give the client only 60 days to appeal a cancelation of benefits from long term disability companies. I also discussed how I sent in my appeal along with a second certified/signature required letter request for my entire case file to be sent to me within the month.

Yesterday marked day 20 of the insurance company signing for said letter and I have heard nothing. I decided to give them a call to check up on the progress of my request only to find out that although they had the letter in their system, and indeed signed for it 20 days ago, they did not have it marked as requiring any follow up. Therefore, for the last 20 days, the company has simply not been working on the request. According to the worker I spoke with (the one who signed the cancelation of benefits letter-- and sounded shocked to hear from me, but then smugly asked how my holiday was) they will send me all of the documentation I requested within 7-10 business days.  I'll believe it when I see it.

Just a reminder of why we need to follow up with companies even if we've gone to all the trouble to send certified letters requiring signatures.

This is not the first certified/signature required letter this company has actively avoided responding to, claiming it was mismarked in their computer system. Therefore, I'm 100% certain it's a common stalling tactic that they hope will cause the appeal to be sent in late, and allow the cancelation of benefits to stand uncontested.

I'm glad I sent the appeal in despite not having all of the information I requested, because at least the process has begun and I'm not panicking over when this box of documentation will arrive and if it will be complete. Let's say I receive the box of information at the 45 day mark-- what if it's not all there? How long would it take me or an attorney to accurately go through it?  Probably more than the week I would have left before I would need to send the appeal letter in and make sure it arrived before day 60.

At least this way, should this case go to court it is not an "easily dismissed on a technicality" situation now.

1974 ERISA Law

I've been thinking a lot about the 1974 ERISA (Employee Retirement Income Securities Act) law since I received my denial letter from the insurance company last week. (Which by the way,  yesterday I received the returned signature cards showing they received the certified letters for both the appeal and documents request).

The reason I've been thinking about ERISA is because it was noted in my denial letter and according to my research this law has been exploited by many insurance companies in order to no longer honor their obligations to policy holders. 

I found two articles/briefs that got me thinking about my own experience. Both are worth a read if you have some time. Specifically the second one that discusses exactly how this law is used against patients in insurance cases.

http://www.patientadvocate.org/index.php?p=443 

and

http://www.patientadvocate.org/pdf/ERISA.pdf

One thing I found surprising is in my own denial letter. The insurance company informed me I had 180 days to appeal the denial. However, with ERISA I really only have 60 days or a judge could throw out any future lawsuit regarding the case. 

I have a solid connection to a law firm willing to represent me, but I wanted to fully explore my options so I contacted a local firm that specializes in ERISA law. When I queried them I received a response back that this specific firm only represents the insurance companies with their knowledge of ERISA, not the patients. Of course large companies with large legal budgets are where the real money is, so from a financial perspective I understand that law firm's decision. I'm saddened though that this firm would use its knowledge to support companies known to abuse this law. 

The loopholes this law offers, I'm sure were unforeseen in 1974. However, over the years companies have discovered new exploitation methods using older laws. It's sad... and we're clearly at a point when these laws need to be changed. 

When I spoke to the insurance person who sent me the denial letter (before the denial was ever sent). He informed me this was "nothing personal"-- it was simply business. 

I would argue, "business" set up on loopholes and a year end bonus structure that encourages vilifying an honest policy holder, is very personal. Making up false claims about another human being in order to receive a year end bonus for saving the company money, is very personal. Trying to use intimidation tactics to harass a client because you know that client is not allowed a jury trial under ERISA, and you will never have to answer for that harassment, is very personal.

I am not a moral authority. I'm just an average human being whose integrity is being attacked by a company for the sake of money. And I'm wondering when the collective "we", as employees, stopped listening to our conscience and instead put all our trust in company policies meant to harm clients. 

I encourage anyone reading this to fully educate yourself on ERISA so you will have some basic knowledge should it ever be used as a tool against you. 

Denial Letters Without Using Facts

Earlier this year I posted a blog with a denial letter I received stating I was denied coverage, because.
http://themalformationofhealthcare.blogspot.com/2012/08/denial-because.html

No, I didn't forget to finish the above sentence. The denial letter I received said I was denied coverage "because." No further explanation.

It turned out the reason I received the denial was because of an inter-insurance-company problem having nothing to do with me. So when the insurance company didn't pay my claim, they had no reason for why it was denied, and therefore left the section blank. Leaving me to panic, call them, and wait until they cleared up their error and pay the invoice prior to me ending up in collections for something that should have been covered through insurance.

Ready for something to top not giving a reason for a denial.....

Drum Roll Please.....

Yesterday, the insurance policy I have held since I had to stop working due to my arteriovenous malformation and chronic myelogenous leukemia sent me a letter listing off several reasons why they have decided to stop honoring their obligation to my claim. They included not hearing back from my doctor (although my doctors name was spelled completely incorrectly and I can only wonder if she even received the documents she was asked to fill out). Partial information from a report done by a doctor who in a video taped interview stated he did not treat either condition I have. Video taped surveillance showing me go into a local business for 3 hours (without mentioning it was a dental office)...And the piece de resistance....

 because my oncologist informed the company that I was in complete remission from AML.

You can imagine my relief to hear I was in complete remission from a condition I was never diagnosed with.

Here's the portion of the letter:

Yes, this denial letter stooped so low as to deny my claim using completely false information.

AML is Acute Myeloid Leukemia. It is a really terrible blood cancer that is difficult to control. I have known two young adults who have battled this disease. One survived it and one did not.  AML is treated with aggressive traditional chemotherapy and often a bone marrow transplant.

I have Chronic Myelogenous Leukemia-- a completely separate condition that currently has no proven "cure" outside of a bone marrow transplant. Fortunately for me, as long as I take a daily chemotherapy pill my chronic leukemia is kept at bay in the body. It is not a traditional "remission" as suggested by this letter. It is a conditional cytogenetic response to a daily chemotherapy drug.

I sent in the appeal letter today correcting their misinformation and requesting my policy to be reinstated. Should this company deny the claim a second time my only recourse is to hire an attorney.

Health Care and Religious Freedom

Can we stop all the shrouded discussion on this topic and call it what it is? The reason religious freedom is being brought up with regards to the new health care law is because of the issues of women's fertility and money. With that I mean contraception, abortion, and the cost to care for the sick.

This is article I read this morning: http://firstread.nbcnews.com/_news/2012/11/26/15456408-supreme-court-opens-door-to-universitys-health-care-challenge?lite

In the article Liberty University is contesting the individual mandate for health insurance due to their belief that because most health care policies allow for abortion and contraception Liberty University's religious freedom is being trampled on (fertility). They are also contesting the section of the bill that states employers must provide health insurance or pay a penalty (money).

You might be wondering why this is coming up again since the individual mandate issue was already discussed and decided on earlier this year by the Supreme Court. The answer is there will always be someone, or a group of someones, who look for ways around decisions. I'm not saying this from a liberal or conservative perspective, I'm saying it from a historical perspective. Our country was built on disagreements and loopholes (example- all men are created equal, but slavery is fine).

The Supreme Court's decision about the individual mandate, earlier this year, was in relation to state's rights.  Liberty University is a private institution and often times private institutions do not have to adhere to certain state or federal laws. Loophole.

I suppose what bothers me about what Liberty University is doing here really comes down to the issue of money being wrapped up in a religious cause. When I think about spiritual principles in health care, I think about caring for the sick, and the poor. I don't think about legal battles to deny coverage for the sick and the poor using convenient loopholes in man made policies.

I feel like there is a disconnect between what the law is intending to do and some religious reaction to it.

Here's an example of what that disconnect can do (note: this happened outside of the United States).

 http://www.reuters.com/article/2012/11/23/ireland-abortion-idUSL5E8MN7YM20121123

A woman visiting Ireland died of blood poising after being denied an abortion when she was already miscarrying. There was no saving the fetus at the point when the woman asked for the termination. However, because of Ireland's anti-abortion law, she was denied the medical assistance necessary. The miscarriage lasted for three days, which presumably caused her body to become septic and she passed away. Abortion in this case would have been used not for the ending of a life, but the saving of life. Which is why I become frustrated when some believe abortion is a cut and dried issue.

We need to reconnect to the human side of health care. If we boycott coverage for medical procedures and people on the premise of religious freedom and an otherwise healthy individual dies because of that boycott--- who is at fault?

I would argue unexamined principles. When we fight so hard against something often times we become blind to the full picture. We focus so intently on the rabbit, that we miss the lion about to pounce.

Thanksgiving for Non-Profit Groups!

Thanksgiving is this week and I'd like to take a moment to thank all of the advocacy groups out there dedicated to helping those struggling with health care.

Groups like

The Patient Advocate Foundation:  http://www.patientadvocate.org/about.php?p=901 
that has an online web-chat to answer specific questions a patient may have regarding insurance access, job retention, and medical debt.

P.S.I/ Patient Services Incorporated: https://www.patientservicesinc.org/how-we-help/default.aspx
that offers co-pay assistance to some patients on extremely expensive medications.

Sy's Fund: http://sysfund.org/
that encourages young adults battling cancer to also pursue their artistic/ life goals outside of their health  battle.



There are so many wonderful organizations out there that I would be remiss to try and name them all. However, I am happy to update this post with additional references if you simply comment below with the name of the organization and what it focuses on.



Blessings to you and yours during this holiday season!