Nearly a quarter of the Texas population lacked health insurance in 2010, according to the most recent data released by the American Community Survey, which the U.S. Census Bureau conducted. That’s more than 5.7 million Texans.It’s likely that someone you know — and probably one you wouldn’t have guessed — doesn’t have health insurance. More than half of the uninsured are employed. More than a third have an annual household income above $50,000. And more than 1 million have college experience or post-secondary degrees.
Very nicely done.
If I get a lesson from this, it’s “Stay in School. kids!” (If you live that long).
And even if you do have insurance, the insurance companies will go to great lengths to minimize the claims they pay out.
I am a Texas breast cancer survivor (Stage IIB, ER+/PR+, Lumpectomy, PortaCath, Chemo Adriamycin/Cytoxan+Taxotere, Radiation). My husband and I are both professionals employed by large companies. We insure through my husband’s PPO plan, and use preferred-providers. I’m lucky. I’m insured, and now I’m healthy.
Throughout my illness we had to fight numerous claims denials, for care that was clearly medically indicated and had been pre-authorized. The most egregious was for radiation treatment prep (CT-Scan, MedPhysics, & mould/cradle). The insurance refused payment on this large bill. Why? Radiation treatment was clearly indicated, had been pre-approved, and the prep was a necessary first step. The problem was that with the Port and the Chemo, I had developed an UEDVT with a 100% blockage of my internal jugular vein and I had outpatient surgery to remove the Port the day after my radiation treatment prep.
After a number of appeals by both myself and the PreferredProvider Hospital, we got to the bottom of the matter. Since I had been admitted to the hospital within 24 hours of the RadiationTreatmentPrep, the Insurer stated that according to their contract with the hospital, the very expensive Radiation Treatment Prep should be thrown in “gratis” with the PortaCath removal — because it involved imaging.
After months of denials, reviews, and arbitration discussions, the Insurer notified the hospital that they would entertain no more appeals. At that point, the Hospital informed us that they were sending the bill to collections. After all, before the hospital treats any insured patient, the patient is required to sign a form stating that they will be responsible for *ANY* charges not covered by insurance. I was now on the hook for this big bill… for services that were clearly medically indicated, and had in fact been pre-approved by the insurer.
If a VP at my husband’s company had not intervened, we would have been stuck with that bill. A bill for services medically indicated and pre-approved, a bill that the insurance company was using a technicality in their contract with the hospital to avoid paying.
I am convinced that if I were individually insured, or insured through a smaller company, this would not have ended as well.
I am also convinced that insurance companies will avoid paying claims whenever and by whatever means possible, and that none of us who *think* we have insurance are as protected as we think we are.
I work on the IT side of healthcare, primarily in finance. A good friend at a vendor used to work at an insurance company. Her first day there, she was told that every cubicle has a sign posted: “Deny it and see what happens”. Because providers don’t routinely fight the $5 or $50 denials. The $5000 denial? Sure. But they are timid about fighting for the small amounts.
The other thing she was told is that when an insurance contract is signed to pay at 80% of reasonable & customary of allowed charges, the computer will be set between 75% and 78%. Because providers won’t fight for the difference between 75% and 80%. Instead, they will shrug and send a bill to the patient. It is easier to bully a patient into paying than it is to fight with an insurance company.
She managed to stay at the insurance company for a couple years before she moved to be the patient financials supervisor at a 400-bed facility, for the sake of her mental health. Her first day, she told her staff that they were going to fight with insurance companies, not patients, because she knew who actually had the money and that they were holding onto it when they shouldn’t. She also told them that the insurance company’s first goal was to make make, so that theirs had to be, too. In 18 months, she turned around the entire financial picture at the hospital, because she was willing to go toe to toe with the same people that she had just been working for and with.