Let’s get a little personal today. I want to give you a little insight into my world.
I write about benefits and health care partially because it’s the field I work it but partially because it makes me angry. Really, really angry. Like Hulk angry! As a patient, the combination of health care and health insurance can be nothing short of a chaotic, frustrating, maddening, and miserable experience.
This all happened about 8.5 years ago….
I have twins who are now a little over 8 years old. At the time, I was pregnant, I worked in benefits for a mid-sized company. Prior to that, I had worked for a large health insurance company. I knew my health insurance stuff. I completely understood my short-term disability coverage. I had even researched local hospitals to find out which one was best for a twin delivery. I also was enrolled in the “Healthy Pregnancy” program that was offered through my employer’s health insurance program which are supposed to help minimize the changes of premature birth. Life was good. I was super prepared.
Then at a routine appoint just shy of 7 months, everything dissolved into chaos as I turned out to be in pre-term labor and very shortly thereafter had my babies. My short-term disability carrier called me shortly after being admitted to the hospital to tell me that my disability was denied because there was no medical reason I couldn’t be working. Obviously, after telling them I had been admitted to the hospital, they contacted my doctor and changed their mind.
At the time, I had done everything the Healthy Pregnancy nurse had advised me. I had done everything my doctors had advised me. I was a VERY compliant patient. So, in all honesty, I was pissed when I had my twins early. As far as I was concerned, that was NOT what was supposed to happen.
It was utterly chaotic. I refused to let the anesthesiologist touch me until he confirmed that he was in-network with my insurance provider. (seriously!) The neonatologists didn’t make it to the room in time with the incubators so two nurses had to wrap the babies up and basically run for the Neonatal Intensive Care Unit (NICU). And we didn’t even have names fully picked out, a camera, or anything prepared. I had to spend a week in the hospital. The babies had to spend 2 weeks in the hospital. It was a total of 3 weeks of 10-24 hours spent at the hospital.
Now that alone was stressful. There’s no worse feeling that having to leave the hospital empty-handed after giving birth. And then having your babies in incubators with tubes and IVs and all sorts of monitors and alarms blaring in the NICU. We were actually quite lucky – we did not have micro preemies that are ~1 lb. We did not have anything seriously wrong. But every day was scary – the other parents who had babies in the NICU all talked about medical diagnoses. There was a bulletin board that the nurses kept of the babies that didn’t make it.
Then, I think the 5th day the babies were there, I got a call from either the NICU or my insurance company informing me that a portion of the NICU was out of network. WTF? How was that even possible? How could someone even know that? Here I was, pretty much an “expert” in health insurance and even I had no clue that it was part of a hospital to not be in-network. And why in the world, would you think it a good idea to tell this to overly stressed out parents who were just hoping that their baby would live? (Recently I’ve heard stories that it’s actually common for debtors to track down parents of seriously ill children in hospitals and rehabilitation homes to get them to make payments)
My ob-gyn was in-network, the hospital was in-network, the pediatrician we’d picked was in-network, and even the anesthesiologist was in-network. But we found out that the neonatalogists that served the NICU were out-of-network. It was the most idiotic thing I had ever heard of. Ever.
I was lucky that I actually ran my company’s health plan. I got someone from the insurance company on the phone and the billing person from the neonatology group on the phone and we talked. Then I got someone from the hospital on the phone as well. And then I also made the insurance rep get someone from provider relations, the network negotiation group, and my case manager from the Healthy Pregnancy Program on the phone. We talked more.
Yes, they confirmed that the neonatalogist were out of network.
No, there were no other neonatalogists that had rights to see patients at the hospital.
No, the network negotiation group wasn’t responsible for making sure everyone that practiced in the hospital was in-network.
No, I couldn’t transfer my babies to another hospital where everyone was in-network – that would cost too much.
But, the case manager would try to negotiate a discount with the neonatalogy group.
Who created such a messed up, convoluted system that is not understandable to the experts – let alone the average patient? Was I perhaps asleep and going to wake up to find that this was just a nightmare?
No. The insurance company tried to negotiate a discount. Their version of “try” and mine were quite different. I took over where they left off – at least once the babies were home and negotiated the bill down so that they finally accepted the amount that the insurance company paid them. Turns out that if you mention the word “media” and “local news interest” then you get to a final deal much faster.
The babies finally made it home – safe, sound, and healthy. We were happy – not sleeping much – but happy.
Then the bills and explanation of benefits starting pouring in. Since the babies didn’t have names at first, they brought them into the NICU as ‘Baby A’ and ‘Baby B’. Somewhere while they were down there, one of the disappeared from the billing system and they both because ‘Baby A’. Since the insurance company viewed it as the hospital submitted duplicate bills – they didn’t pay for ‘Baby B’.
More phone calls to get it straightened out. After 3 or 4 attempts, it finally gets corrected once I insisted that they please start billing the babies under their names.
When you have preemies, you end up having in-home nursing and follow-up appointments galore with opthamology, cardiology, hearing tests, neurology, and random preemie doctors that feel the need to tell you how far behind your baby is compared to other children after doing a battery of physical, occupational, and social tests.
All of that comes with another host of bills. Some right. Some wrong. Sometimes it’s the fault of the provider – they forget to submit the bill to the insurance company for a year and then expect payment. Sometimes it’s the fault of the insurance company – denying one of the claims as a duplicate even though there are two babies. I loved the providers who knew how to work the system to bill correctly or who would fight with the insurance company on my behalf.
Now, they are happy and healthy. We are very lucky.
But, the entire process was just a labyrinth of confusion. The people that use the most health care dollars are the sickest people. If I can’t figure things out, how in the world is anyone else expected to? When all of the baby boomers hit Medicare age and start having serious health problems, who will help them navigate through this chaos? When kids graduate from high school or college, they are not even given the barest minimum understanding of health insurance and sometimes health care in general. Who will help them?
I write because I care. I write because there needs to be people questioning the structure of the system itself. I don’t care if you are for or against “Obamacare” – I care that it does NOTHING to help alleviate the problems of sick people trying to navigate their way through the system. Medicare and group health insurance are equally confusing – the rules are pretty much the same.
I want the patients or their families to understand what is going on and what to do when they are stuck. I want the employers to step up and start making health insurance easier for their employees – not harder.
No one should have to deal with silly, administrative bureaucracy while they are dealing life decisions for their loved ones.
Sidenote: In case you are wondering, the total billed amount for our stays was about $108,000. Insurance paid $21,600. The rest was the “discount” amount.