Posted by WMD | The health inusrance industry is likely to trip over itself in attempts to discredit the claims made in Michael Moore's film "SiCKO", so CNN has provided a link to "fact check" Moore's statistics. It includes a short video of Larry King interviewing Moore. Hey, he actually comes off as rational and intelligent!
Rubbing salt into the wound, Moore has posted on his website the text of an internal memo from Capital Blue Cross VP of Corporate Communications, Barclay Fitzpatrick. It's that executive's reaction to and p.r. talking points for thier employees to use in response to Moore's film. Moore generously shares that executive's email address.
Its an opportunity I cannot resist so have emailed Mr. Fitzpatrick with my own health insurance company story that you can read on the next page.
To: Barclay Fitzpatrick, V.P. Corporate Communications, Capital Blue Cross
Dear Mr. Fitzpatrick;
My experience with my health insurance company sadly validates what you saw in Michael Moore’s film, “SiCKO.” The details (recalled below) are from the inch-thick logbook I kept from December 2001-2002.
It's time we, as consumers, acted which is why I've sent this email to you. You will notice that it has also been posted on BuckNakedPolitics.com blog as well as emailed to selected elected officials and media outlets.
My husband and I contracted with one of America's top health insurance companies for full coverage in 1987. The next year, at age 31, I had my first child and two years later my second.
Later, through a routine blood test, my doctor discovered there was something wrong with my liver. It was Hepatitis C Virus (HCV) – a blood borne virus that destroys the liver: I contracted it from a blood transfusion I had needed years earlier (before the medical community knew HCV existed).
Upon diagnosis, I was referred to a gastroenterologist who prescribed the only treatment available: injectable interferon (pegintron) and ribaviron (rebetol) pills. This FDA approved chemotherapy was proven successful and was the best hope of a cure. It required patients to endure 48 weeks of treatment and a long list of side effects. And it was very expensive.
The only other option was to do nothing, allow the virus to ravage my liver to the point of failure, and pray I could find a liver donor in time.
The responsible choice was to begin chemotherapy immediately while I was still young and healthy. Despite its $25,000+ cost, we were comforted by the fact that we were covered by one of the best health insurance companies in America..
Or so we thought.
In December 2001, I ordered the chemotherapy drugs from my local pharmacy and paid the approximately $2,000 for one month’s supply. Because of the assault these drugs exact upon the body and it’s immune system, the medical protocol required monthly blood tests and doctor’s visits to be sure the drug wasn’t doing more harm than good.
As required by my health insurance company, I submitted the completed claim form with receipts. The insuracne company sent me a denial letter stating, “Your claim was for a medication not covered by your plan.” I contacted the Customer Service department for clarification.
A representative (someone named Kim) told me that because one of the drugs was an injectable it was not covered (then why did they reject the claim for both drugs?). I re-read my policy and saw that indeed they could reject such a claim. When pressed, Kim was unable to logically explain why injectables were not covered.
I couldn’t understand why an insurance company would refuse to pay for treatment that would cure me. Kim explained that my policy states that they could refuse coverage for any reason, even if a doctor deemed the treatment “medically necessary.” Kim explained it is the insurer who determines if something is medically necessary, not my doctor (despite his being board certified and a Diplomat of both the American Board of Internal Medicine and Board of Gastroenterology).
I asserted that without the chemotherapy, the HCV infection would continue, my liver would become more diseased and they would end up paying for a liver transplant one day, costing hundreds of thousands of dollars (which is covered by my policy). Kim said she would talk with her supervisor and call me back.
After a few weeks no one called me, so I called them and spoke with one of the representatives (someone named Sherry). She told me I would need to get my doctor to send a letter of “medical necessity” for review by their “Medical Review Board,” and the decision would take a few days. In January 2002, I faxed that letter to the Jacksonville claims processing office per their instructions.
In February, I finally received notice that reimbursement would be sent -- but for less than half the meds’ costs. Due to the high cost of these drugs and the required monthly doctor’s appointments and blood testing, my $1,000 deductible had been satisfied in the first month of treatment. I quickly surpassed the out-of-pocket threshold where the insurer would then begin to pay 100%.
I called the Cusotmer Service claims processing office again. The representative (someone named Jennifer) informed me that they pay only the “reasonable amount the market charges for a drug” and that my pharmacy had overcharged me.
Incredulous, I called my pharmacy and seven others to ask about pricing for my drugs. All seven verified that they charged roughly what my pharmacy charged (they were all within just a few dollars of one another). Apparently “the market” here was pretty level.
I also called the drug manufacturer, Schering Corp., to see what they charged these pharmacies. Explaining that there is some minor fluctuation in pricing, they verified that my pharmacy and the seven others were charging what Schering’s costs are to them, give or take a few dollars.
Armed with this information, I called my insurer. Someone named Jason said it needed to go before their Medical Review Board.
At this point, I had been on chemotherapy for nearly three months. The difficult side effects were taking hold and I was not well. But I had spent nearly $6,000 on the drugs, doctor’s visits and blood tests and was getting pretty cranky from this run-around. Clearly they were stonewalling me and hoped I would just give up and go away.
They were wrong.
I pointed out to Jason that my case had already gone before your Medical Review Board. Jason countered with the old “We need a letter of medical necessity from your doctor.” They already had that letter. Being a well-trained employee, Jason said the letter needed to list my prescribed dosage. “Baloney,” I replied. The dosage was the same for everyone and was printed on the three months of Rx and cash register receipts that the claims department already had. When Jason insisted on a new letter from my doctor I lost my cool. He saw I wasn’t backing down so agreed to take it to someone named David on the Medical Review Board. I was told to expect a call back.
Having heard nothing from them, I called again a few days later. This time, I spoke with someone named William, who told me it was still in the Medical Review Board’s hands. Facing more stonewalling tactics, I turned up the heat on poor William, and he transferred me to Jason. Reluctantly, Jason informed me that they would pay the full amount for the chemotherapy.
Finally!
In mid-February I mailed in that month’s claim forms/documentation and waited for reimbursement. By early March, I had not received payment and reminded your claims department of this when submitting my March claim form/receipts. This non-reimbursement continued, so I called Customer Service. A representative (someone named Billy) told me they could not read the receipts. Yet another stonewalling tactic: I had sent them the originals, and my copies clearly showed all pertinent information was legible. After more phone calls and faxes, I assumed things were worked out.
I assumed wrong.
July was like the previous months, only I was talking with still another employee (someone named Angela). It’s hard to determine if their filing system was severely flawed or the employees are instructed to deny everything right off the bat, but I was again told that they wouldn’t pay the full amount for the injectable drug. They also could not explain why my reimbursements were months behind schedule.
By this time they had turned my file over to a supervisor (someone named Donna), who assured me she would handle my claim from this point forward. Thank goodness - someone with a little authority!
In August, I received a letter from another supervisor (someone named Winona; what happened to Donna?), informing me that the Medical Review Board needed to look at how much they had been reimbursing me for the injectable drug and that a lesser amount might be allowed. Back to square one.
Meanwhile, I was eight months into chemotherapy treatment. I was experiencing chronic fatigue and flu-like symptoms inlcuding muscle aches, headaches, nausea, alopecia, depression, insomnia, weight loss (at 5’4” I had dropped from a healthy 120 lbs to 100 lbs). My children couldn’t understand why mommy stayed in bed so much. Yet, I did not want to be thousands of dollars in debt so mustered the energy to constantly call, fax and write the Customer Service Department and Medical Review Board.
From August and into September, Winona and I got to know one another pretty well. We had a series of phone calls, faxes and letters that documented who said what and the disposition of my claims. By late September, I began dealing with yet another Customer Service representative (someone named Sandy), since Winona was “out sick.” I remember hoping she had good health insurance.
The claims department just could not figure out what they were going to pay for and when. Sandy and I continued our communications but made no progress. By the time Winona was back to work, I had been faxing duplicate copies of claim forms and receipts going back months. Hadn’t they kept any of the stuff I had sent? Were they hoping this run-around would overwhelm a chemotherapy patient and I’d simply give up?
By October, the reimbursement checks were coming in but were always very late and for the wrong amount. But at least my persistence was paying off somewhat. I had one more month of chemotherapy and this nightmare would be over.
Incidentally, like clockwork my health insurance company sent me bi-monthly premium notices which I paid in full and on time. How is it that they could efficiently manage billings but not manage the paperwork for my claim?
In the end the chemotherapy treatment worked and I have been clear of the HCV since 2002. My liver is functioning normally and I feel terrific.
But I think about the thousands of other HCV patients who did not have the temerity to fight over coverage with their health insurance company. How many of them still harbor HCV while their overall health declines as a result? How many had to take out a second mortgage to pay for treatment? How many had to file for bankruptcy?
Your talking points to counter the film “SiCKO” are too little too late. Thousands, if not millions, of Americans just like me have their own stories about how health insurance companies use various ploys to avoid fulfilling their part of our health insurance contracts. We now know our stories are not isolated and America is learning how sick our health insurance industry is.
Respectfully yours,
Someone named Susan
Comments