[I know I should be glad I have adequate health insurance and am a smart cookie and can figure out when someone else is trying to pass on their stupid coverage mistakes to me. But I’m not glad. I’m Type A, and quick to anger, and also eager to put everyone else on the qui vive. [Look, look! Look what happened to me! ]
Life is full of relatively small things that aggravate and take up precious time to rectify. You can be philosophical (although I’ve never found that approach really soothing) when, for instance, a box of paper clips falls from your fingers, opens, and scatters its contents all over the floor — or worse, the rug. But do you leave the mess there, for the cats to play with? And for you to re-discover when you return from whatever you were rushing off to with those papers that needed a paper clip? Or do you take the time to vacuum up, possibly clogging the vacuum hose and certainly losing a boxful of clips? Or — an even more time-consuming option — do you laboriously pick them up one by one, even the ones that scooted under the desk, fuming all the while — and be really late to wherever?
Well, the fall of the clips was probably your own fault. (Clumsy you.) So is discovering you’re practically out of gas when you’re hurrying somewhere, and then having to get yourself to the nearest gas station as fast as possible before moving on to your destination — only to find a long line at each of the pumps. And if something’s not your own fault, you probably can find a loved one to blame. The cats for the box of clips, Bill for the near-empty state of the gas tank.
But what do you do when someone, or several someones, who you don’t know at all, and never even knew existed, is just plain sloppy or dumb on the job, and you wind up losing much of your afternoon — plus some of the next day, and possibly more time to come — trying to keep your blood pressure down while you extricate yourself from unsought and unmerited liability and expense? If you’re smart (or used to be a lawyer) — you eat the time, choke down the bile, and deal with it, so that, hopefully, it will get been resolved once and for all. Even though it should never have arisen in the first place.
And what if you’re less smart, or don’t think fast when you get stupid explanations for why strange things are happening, or are too inexperienced to ask the right questions in the first place? Well, that’s some unfortunate other person’s blog post, involving even more aggravation and grief. This one is mine — and while it’s true that my aggravation has been of limited duration, and cost me only parts of two days I was planning to devote to something else, plus $6.49 in unforeseen postage charges — it was more than I should have been subjected to. After all, I was the entirely innocent party in the transaction. But perhaps it may serve as a sort of Aesop’s fable about tiptoeing through the computerized minefields of the American health insurance system, complete with a short “moral” at the end.
Okay, up with the curtain. Here’s what happened. I don’t know if something of the sort could occur under a single-payer insurance system. But here in the States ours is far from single-payer, as anyone who’s been paying attention to the history of Obama’s struggles in Congress to provide nearly everyone with affordable health insurance coverage can attest. However, leaving that aside, the closest we have to single-payer coverage is Medicare, which kicks in when you turn sixty-five. If you have a social security card, or are eligible to apply for one and do, you will automatically receive some hospital coverage, and are able to apply part of your monthly social security benefit to the premium for covering some of your out-of-hospital medical costs.
Original Medicare was therefore entirely single-payer, even though the insured was paying the government a small premium for part of it. Subsequently, private insurance companies were legislatively enabled to offer insureds Medicare “plans” which monkey with the original concept, and of which I disapprove, so I can’t tell you much about them. I have the original Medicare coverage, which is, in the “service provider” trade, known as my primary coverage.
I also buy what is known as “Medigap” coverage from a private insurer (in my case Medex, the Medigap coverage sold by Blue Cross, Blue Shield of Massachusetts, the state in which I was living when I turned 65), for which I pay a hefty annual premium. I buy it because not only does Medicare not pay the entire “service provider” charge for a hospital stay or a doctor’s visit or a “procedure” or whatever; it also approves only a certain amount of the charge, and does not pay all of what it approves. The Medigap coverage you choose (if you choose it) then pays the remainder of the approved amount, up to 50% of it, usually more than enough to take care of it. And what of the difference between what the doctor or hospital or other service provider initially charged and what it received as an “approved amount” from the primary and secondary insurers? They have to say bye-bye to that overly demanding part of its bill. Any provider which accepts Medicare payments must accept the “approved” amount as payment in full. (That part is important to this piece, which is why it’s in bold italics.)
When Medicare pays a service provider, it sends you a “Claim Summary” which tells you the name of the service provider, the date of the service, the amount charged, the amount Medicare approved, and the amount Medicare paid. When your Medigap insurer pays a service provider (after Medicare has identified the “approved amount” and made its payment), it too sends you a “Claim Summary,” telling you most of the above, plus what Medigap paid, plus what’s left over for you to pay (except a service provider that accepts Medicare can’t collect this part from you). On the former-lawyer principle that if you throw away a piece of paper (a “document”) you will probably need it in future, I keep all mine stashed away in reverse chronological order in a big black box that moves from my office to the basement every year, to be replaced by a new big black box. I almost never look at the Claim Summaries before I put them in the currently open big black box, and have never had a reason to hunt up a Claim Summary to prove anything afterwards. Still…. After four or five years, I do throw them away, though.
You may remember a piece I posted in March which was captioned “The Ugh Factor in Getting Old.” It was about preparing for and having a CAT scan after a prior ultrasound showed something obscure but questionable. All ended well medically. But that was just the beginning of the paperwork. About ten days ago, a Medex Claim Summary arrived for the ultrasound.
A day after that another one arrived for the CAT scan.
I’ve shown you only the top parts, because that’s all that’s relevant here. Actually though, the Claim Summaries are on 8 1/2″ x 11″ paper, and are always mailed folded in half. So blasé am I that I didn’t even unfold these two until it was time to stuff them in the currently operative black box. (Nor did I remember whether they had each been preceded by a similar claim summary from Medicare, as should have been the case. As it turned out, they hadn’t been.) But when I did unfold them — surprise surprise! Each had a check made out to me attached on its bottom half. The first check (in connection with the ultrasound, for which $733 was alleged to have been charged by Princeton Radiology, the “service provider”) was for $715.00. The second (in connection for the CAT scan, for which $3,258 was alleged to have been charged by the same “service provider”) was for $2,576.00.
$3,291.00 for me? This had never happened before. I have never seen the money that passes, probably electronically, between my insurers and providers of medical services. Reluctant though I am to turn away cash in any form, especially in such an especially welcome large amount, I knew — just knew — I wasn’t supposed to put nearly 3,300 unexplained dollars in the bank or go on a spending spree.
“Call Princeton Radiology,” said Bill.
“What good will that do?” I said. “They’ll just take the money before I know why I’m suddenly in the middle here. No, no: it’s Medex which should explain.” So I looked up the phone number for insureds on the back of my Medex card, kissed the rest of the afternoon goodbye, and waited through about ten minutes of “All of our customer representatives are busy, but your call is important to us; please stay on the line” interspersed with music deemed “popular” by someone but not popular with me. Finally, when I was already chewing the inside of my mouth, “Danielle” took my call. (Why are perfect strangers in Customer Relations always on a first-name basis with you — making you sound stuffy or stuck-up if you insist on being addressed as Ms. Mishkin or Nina Mishkin?) Did she want to know why I was calling? No. First she had to be sure I was me. (Come on! Who else but me would be complaining about receiving an unexpected $3,291.00?) We first reviewed my account number followed by the pound sign, my address, my home phone number, the county I live in, my mother’s maiden name, and my social security number before she asked how she could help and I was allowed to tell my story.
Danielle didn’t know why I had suddenly received two checks from Medex, and in such substantial amounts, for the first time in the more than seventeen years it had been my secondary insurer. She asked if she could put me on hold while she consulted a claims “specialist.” (Would I say no?)
She must have asked because I was on hold for quite some time. All the claims specialists must have been busy helping other insureds. Danielle came back on the line every five minutes or so to assure me that it would only be a little longer. Ha! Finally, she was ready to transfer me to “Mark.”
Mark, thank God, didn’t need my mother’s maiden name. Just the number on my card, followed by the pound sign. We went through my story again. Mark listened attentively, but in the end didn’t know any more than Danielle about why I had received those checks. He went off to find out, after asking if it was all right with me to hold while he consulted Accounting. At least Mark had no ability to ease my waiting time with popular music; this time I did my holding in silence. I suppose if I were a crossword puzzle aficionado, as many of my contemporaries seem to be, I could have put all that time on a silent telephone to good use. But I’m not, and I didn’t, and eventually Mark came back from Accounting with the “good news” that I’m supposed to pay Princeton Radiology myself. That’s what the checks were for.
We had by then chewed up nearly an hour of my time. “Why now, after seventeen years of coverage, am I suddenly in the middle?” I demanded. “I don’t want to be in the middle. I want Medex to take care of it. That’s why I’m paying you those obscene amounts of premium money!”
“Accounting says we can’t,” said Mark peaceably. “Princeton Radiology is a provider that doesn’t take Medicare. And we only pay service providers after Medicare does.”
“That’s ridiculous,” I said, beginning to sound — as well as feel — angry. “Excuse the language, Mark, but that is absolute crap! Princeton Radiology has been happy to take Medicare, and Medicare’s payments for the services it provided to me, during the whole eight years I’ve been in Princeton. They took it for mammograms every three years, for ultrasounds of the abdomen every year or so, even for a CAT scan of the lungs four years ago.” Memories of signing papers in which I assumed liability for any “service” Medicare refused to approve began to come back to me. I told Mark about that, too.
“And look, ” I added, really wound up now. “If neither of these so-called “procedures” is covered by Medicare, I will have to pay an additional $660.94 for the CAT scan, as well as $17.02 for the ultrasound, over and above the amount of the checks. I would NEVER have agreed to submit to the scan if I’d been informed it would cost me anything, much less an amount as large as that!”
Mark mumbled something.
“What’s more,” I threw in, “your very own Claim Summaries state that Medicare allowed $431.79 for the CAT scan and $157.68 for the ultrasound — both of which sound low to me. But if Medicare “allowed” anything at all, however low, Princeton Radiology must have submitted its bills to Medicare for these numbers to appear on your Claim Summaries.”
He caved. “Let me call Princeton Radiology. Do you have the number?”
With Bill’s help, I found the number for him. (It took us another ten minutes. Mark didn’t seem to mind. Time is nothing to those guys in Customer Relations.) Then he put me on hold again. For what seemed a very long time, even though by then I was getting used to long “hold”s. After which he came back and said he would have to speak to Accounting again. After which it was almost the end of the afternoon, and I hadn’t written my blog post for next day, or paid some legitimate bills, or gone for a walk on a (finally) glorious Spring day.
When Mark finally returned with some answers, you’ll never guess what he had to say! Someone had made a billing mistake. No kidding! But was it Medex? No siree! It was Princeton Radiology. They had billed Medex as the primary insurer, not the secondary. That’s why I had received the checks. Hmmmm. But not to worry. Princeton Radiology, possibly contrite (although I doubt it), was putting a “hold” on my account and rebilling everything properly. I wouldn’t be liable for anything.
“Who did you speak to over there?” I asked, pen in hand. He told me. At this point I was writing everything down: the transaction number for my multiple conversations with Danielle and Mark, plus the fact that Mark had obtained his information at Princeton Radiology from one Mary Jean. (No last name, of course.)
“And what am I to do about the checks? Can you void them? Can I just tear them up?”
Apparently neither of these options was available. I would have to send them back. Mark gave me the mailing address.
“Tell me,” I asked. “Why do the Claim Summaries state that Medicare allowed certain amounts for these two procedures if Medicare never received the Princeton Radiology invoices?”
Mark really didn’t want to go there. “Well, Accounting just had to put something,” he said evasively. “There’s a place on the form, you see? But never mind that. It’s all being rebilled anyway.”
A place on the form? That sure wouldn’t hold up in any court I knew of. But since it was nearly five o’clock, I decided not to mind, despite the fact I really did. However, I did not take Mark’s advice to just drop the checks in the mailbox. The next day I invested forty-five additional minutes in driving to the closest post office at which I can easily park and in waiting on line to pay a certified fee and return receipt fee, totaling $6.49 — so that I should have proof I sent both checks back. Because having lived as long as I have, I don’t trust anything to go right if it can possibly go wrong.
While driving there, I also figured out why Princeton Radiology suddenly began billing Medex as my primary insurer after seventeen years of billing it correctly as the secondary. I remembered that just before the ultrasound that was eventually the cause of the CAT scan, Princeton Radiology presented me with a whole sheaf of new forms to fill out. Why? When they had all this information already? Because they were changing over to a new and more sophisticated computer system! And you know what that means? Before the new sophisticated system is up and running, someone has to enter into it, with old-fashioned ten-finger technology, all the handwritten information I put down on the sheaf of paper as well as everything every other radiology client has written down on similar sheafs of paper. Data entry! Boring, boring, boring. Room for error? Oh boy, is there! I picture some young thing, thanking God it’s Friday and dreaming of her weekend plans as she tediously transfers my insurer information into Princeton Radiology’s new data bank. She makes, and fails to catch, a teeny weeny little mistake. She’s only human.
As for the mysterious appearance on my Medex Claim Summaries of amounts “allowed” by Medicare (when Medicare had never received the invoices for services involved) — that was, I think, worse than a young thing daydreaming her way through a data entry job. Someone had made up a figure to fill in a blank because the form required it, which was easier than inquiring why an insured always before covered by Medicare for services provided by Princeton Radiology suddenly wasn’t. Or than going to get another form, to be used for non-Medicare-covered invoices. If anyone had done either of those things, it would have alerted me — even if I had not remembered to ask the right questions — not to follow Mark’s advice to pay Princeton Radiology with the two checks; I would have known that if I had done that, I would also have been liable for the amount remaining: $697.02.
So what is the moral here? Setting aside the problem of boring jobs, which is no longer my problem, perhaps the moral for those of us no longer needing to thank God it’s Friday is not to assume it’s all going to be smooth sailing from here on in. Don’t think you left paperwork aggravation behind you in the work force. It pursues you into the grave. So if you’re a Type A like I am, you might consider investing in a meditation tape.
Like I just did.