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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 22 of 22. This is the beginning of the thread.
Posted by mair on November 8, 2002, at 16:56:08
My pdoc practices in an adjoining state, but she is a provider with my insurer so she bills me only for my co-pay amount and only after she's been paid by my insurer first.
My therapist used to practice in the same adjoining state, but now practices nearer to where I live. (I live in a town which is on a state border) She is not an approved provider. I pay her and then seek reimbursement from my insurer by submitting my own claim.
I've been trying for about a year to get one claim paid for services rendered in November, 2001 when my therapist was still practicing in this adjoining state. My insurer screwed it up a couple of times because it seemed to confuse them no end that she was, at the time the claim was submitted, practicing in one state, but she was practicing in the other when the services were rendered.
Anyway, they finally just sent me an Explanation of Benefits which clearly indicated that what was owed to me (actually slightly less) was paid directly to my pdoc, NOT even to my therapist who actually provided the service. The 2 are not in practice together, nor have they ever been. My pdoc hasn't cashed the check, but she can't quite figure out what she should do with it. I don't want her to pay it over to me because it's not the right amount anyway, and I have since resubmitted my claim for the umpteenth time.
Lately something seems to happen with every one of my claims - I'm pretty convinced that my insurers thinks that if they keep screwing up my claims, I'll just stop filing them. That strategy may work - I do sometimes question whether therapy is worth the aggravation I go through to get reimbursed, and I find myself mentally taking the insurance company's side and feeling apologetic about the high cost of my therapy. Lately, my company has been paying out more in benefits than my family pays in premiums on an annual basis, and they're forced to do this because my group policy is "unmanaged" mental health care.
I feel pretty guilty about this, but also very worn down with all the benefits screw ups.
Just a rant...
Mair
Posted by Ted on November 8, 2002, at 17:41:39
In reply to Insurance Company Purgatory, posted by mair on November 8, 2002, at 16:56:08
Hi Mair,
Some things to keep in mind:
1. Insurance companies are businesses. They are in the business of collecting premiums, not writing disbursement checks. Writing checks hurts the bottom line.
2. Intelligent people cost money. Therefore, the insurance companies hire the most moronic idiots available. Having idiots run the company has several benefits: 1. your problems will never be solved, so you will eventually go away; 2. they won't lose any money on disbursements because they won't happen; 3. when nothing happens, they can honestly say "we're working on it" because they are so stupid they can work on it all their lives to no avail; etc.
3. You are not in purgatory. You are not stuck on your way to heaven. You are actually in INSURANCE HELL.
Remember: They don't care. They don't have to. They are the Insurance Company.
An equally disillusioned and frustrated....
Ted
Posted by Dinah on November 8, 2002, at 17:49:04
In reply to Re: Insurance Company Purgatory » mair, posted by Ted on November 8, 2002, at 17:41:39
I'm so sorry Mair and Ted about your problems with the insurance company. I'm fortunate to not have to deal with them that much. My pdoc is off network and they reimburse at a low rate. My therapist isn't reimbursed by insurance at all. But it sounds very frustrating.
But gosh darn it Ted, you're just too funny. Your post made me laugh so that it was hard for me to keep a proper sense of sympathy and empathetic frustration.
Thanks for the smiles.
Dinah
Posted by Ted on November 8, 2002, at 18:21:58
In reply to Re: Insurance Company Purgatory » Ted, posted by Dinah on November 8, 2002, at 17:49:04
Hi Dinah (and Mair),
> My pdoc is off network and they reimburse at a low rate.
Ditto. Really low. Like NEARLY ZERO! All the pdocs in the network are scumbags with horrid reputations and questionable business practices.
I am supposed to get 50% of the "Reasonable and Customary" fee reimbursed for the first 10 appts, then zero. They must measure the "R & C" fee based upon fees in Wichita, KS, not the SF Bay Area. My pdoc charges $120 for a 15 minute appt, which is an average price around here. I get around $45 reimbursed.
(BTW, a quick calculation gives around $750 000 a year salary assuming 4 weeks vacation and 20% overhead for his tiny office. Pretty nice, eh?)
> My therapist isn't reimbursed by insurance at all.
Nor mine. She is supposed to be, at least for 10-20 visits per year, but see my previous post if you need an explanation why I have given up trying.
> But it sounds very frustrating.
That term is just not quite right.
Try ~hopeless~> But gosh darn it Ted, you're just too funny.
Ummmm.... thanks. :-)
"Laughter is the best medicine"
"If you can't beat 'em, join 'em". I do things to baffle and confound my insurance company as often as possible. But with such morons, baffling them is child's play.
>Your post made me laugh so that it was hard for
>me to keep a proper sense of sympathy and
>empathetic frustration.My point indeed. :-)
> Thanks for the smiles.
You're welcome. Anytime.
Ted
Posted by mair on November 8, 2002, at 20:58:49
In reply to Re: Insurance Company HELL » Dinah, posted by Ted on November 8, 2002, at 18:21:58
Thanks Ted - your post(s) gave me a chuckle too - particularly the bit about being able to truthfully say they were "working" on it.
The trick my insurer employs is to have the most wonderfully friendly, courteous and genuinely helpful customer service reps you could ever ask for. The problem is that they don't make any decisions and don't have anything to do with processing claims. They'll glance at my records in the computer, see that my policy should be paying, and then tell me that they can't figure out why my claims are getting lost or rejected or just ignored. They promise to "look into it" and there things end. Aside from the claim that's causing the current headaches, earlier this year it took over 7 months and numerous inquiries and promises before one customer service rep finally figured out that 7 months of claims were getting either rejected or just plain not processed because my therapist failed to get a new "number" with them when she moved her office. This mystery "number" is apparently necessary regardless of whether you're a provider or not. The customer rep who called me with this news had last spoken to me maybe 3 months before that. I know they all work in the same building, but clearly the mysterious "ways" of the claim processors are as much a mystery to the cusotmer service reps as they are to me.
These are just this year's problems. Last year their deal was to promise a 21 day action program where they'd take action on a claim within 21 days of its submission. I discovered that it was a real Catch 21 for me as to whether I should call to find out what happened with one of my claims because as soon as I made an "inquiry," they'd note that in their computer and my phone call would trigger a new 21 day response period.
I know what you mean also about the absurdity of "normal and customary charges." Both my husband and I see a periodontist. Our dental insurer is supposed to cover 50% of this. One of us will have a semi-major procedure that will cost $300, say. The insurer's "normal and customary charges" are $80, and they will then reimburse us $40 for the 50% share. One can't help but wonder where those professionsals are who are charging $80 when everyone else is charging $300. Surely not in my area or else they'd be driving everyone else out of business. How can it be a "normal and customary" charge if it's not at all available to you at that price.?
I bet we could all go on and on.
Mair
Posted by Tabitha on November 9, 2002, at 4:20:20
In reply to Insurance Company Purgatory, posted by mair on November 8, 2002, at 16:56:08
Goodness. Sounds awful, and awfully familiar. My last company had a separate insurance policy for mental health (probably to get around the parity laws) and every claim was a huuuge hassle, requiring months of back-and-forth, phone calls, and even getting my employer to call them once (how embarassing). My claim was identical every year, and every year a new runaround. I suspected they were just making it sooo difficult that people would give up. All that, and they only paid about $700 per year anyway.
New company, new insurance policy, overall worse coverage, but somehow someway they pay an enormous amount for therapy, and no hassle at all. I go for months without paying my therapist a dime, they reimburse so much. I'm afraid I'll be single-handedly responsible for my company losing their coverage or something.
It's just totally random.
Posted by NikkiT2 on November 9, 2002, at 7:51:08
In reply to Re: Insurance Company Purgatory, posted by Tabitha on November 9, 2002, at 4:20:20
It really sounds awful over there to get decent health care at a decent price.. how can you all afford this?? I know I complain about the UK National Health Service, but at least we know we will get seen (eventually!) and not have to pay for it.
I do have insurance, but it doesn't cover mental health, so ahve bene stuck in the system for ages... I've been on the waiting list for a Therpaist for 13 months now and they say it will be about naother 8 months before I am seen!!
BUT, at least I won't go bankrupt when i do see her...I really feel for you guys... must be awful to have to find to money for these things on top of having mh problems.. *sighs*
Nikki
Posted by judy1 on November 9, 2002, at 19:49:07
In reply to My god.. sounds awful!, posted by NikkiT2 on November 9, 2002, at 7:51:08
All the shrinks on my insurance list are questionable at best. My husband has a certain amount of money taken pre-tax for health costs that I use to pay my shrink and therapist. At least we save that way- and they reimburse mileage too. Is that an option for anyone? take care, judy
Posted by Dinah on November 9, 2002, at 20:06:15
In reply to I agree...., posted by judy1 on November 9, 2002, at 19:49:07
That's how I work it too, Judy. They don't reimburse for mileage, and my therapy bills usually exceed the maximum so I pay the rest out of pocket. It does help though.
I'm not sure I'm all that unhappy about working it that way. And I don't know that I'd try to find a new therapist within the network if I could. It just seems so much safer and more private without some health insurance company looking over my therapist's shoulder to make sure I really need therapy. Especially with all the special certification procedures needed for mental health care.
Posted by BeardedLady on November 10, 2002, at 7:08:02
In reply to Re: I agree.... » judy1, posted by Dinah on November 9, 2002, at 20:06:15
My insurance company has a terrific mental health benefit. Every six months, my doctors fill out of a form saying how many sessions I will need, and if it changes, they fill out a new form. It's always been approved.
I don't know how active a role an insurance company can play in looking over therapists' shoulders. As far as being in network goes, it's a considerable savings, in spite of the insurance company wanting to make sure you're truly in need.
Sorry, Mair, about your troubles. I've been through similar ones. I just paid off a two-year-old visit to the emergency room because the insurance company kept getting it wrong. The persistence doesn't ever seem to pay off, but if fewer people tolerate insurance company crap, then they might get the hint that they need to shape up.
Nah.
beardy
Posted by Miller on November 10, 2002, at 16:06:07
In reply to Insurance Company Purgatory, posted by mair on November 8, 2002, at 16:56:08
I just needed to put my two cents worth in here. I used to work for a collection company that delt with insurance all the time. There are two very important things to remember when dealing with your insurance company. The first is that you are able to dispute any decision of their's that you feel is unfair. It would take writing a letter to the insurance company directly requesting a formal review of the decision. (Always keep a copy of all correspondance.) Second, if you have strong complaints that you feel need to be addressed, the insurance companies are regulated by The Office of the Insurance Commisioner in each state. You always have the right to register a complaint through them as well.
In my own experience I have learned that speaking with supervisors and department heads will get results more quickly than trying to deal with the average customer service rep. that answers the phones.
I hope this helps.
-Miller
Posted by ShelliR on November 10, 2002, at 20:36:31
In reply to looking over therapist's/psychiatrist's shoulder, posted by BeardedLady on November 10, 2002, at 7:08:02
> My insurance company has a terrific mental health benefit. Every six months, my doctors fill out of a form saying how many sessions I will need, and if it changes, they fill out a new form. It's always been approved.
>Hi Beardy,
Just curious. What is the largest amount of therapy they've covered for you in a six month period? I guess I wondering if you needed therapy x2 weekly for a couple of years, whether they'd support that. Because some pretty serious disorders do require that intensity of treatment, and then I *would* be pretty impressed by your insurance policy. (my impression from other posts of yours is that your "need" for therapy has been rather minimal--did I get that wrong?)
Shelley
Posted by BeardedLady on November 11, 2002, at 7:04:36
In reply to Re: looking over therapist's/psychiatrist's shoulder » BeardedLady, posted by ShelliR on November 10, 2002, at 20:36:31
You're right, Shelley. I went weekly for about a year with my psychiatrist, and weekly for about six months with my therapist. (In the beginning, I went twice weekly.)
But my Blue Cross is also a very liberal policy. The insurance company hasn't questioned the doctors' judgment in my case, and I have had several more-frequent therapy sessions.
They also paid for accupuncture treatments! (My copay was $10.)
I'm sorry if my post was misleading. I guess because I have not been in such severe need, I didn't realize it would be different. I'm sure there are coverage limits in my policy too--that once I got over $5,000 per year (or some odd amount), I would have to pay for my own therapy out of pocket.
Still, some insurance coverage would be better than none, I would think.
beardy
Posted by judy1 on November 12, 2002, at 11:49:10
In reply to Re: looking over therapist's/psychiatrist's shoulder » BeardedLady, posted by ShelliR on November 10, 2002, at 20:36:31
I think the average insurance policy covers 20 visits/year except in CA (and other states) where they have parity for severe mental disorders- schizophrenia, bipolar, MDD, and panic I think. Since I'm in that category there is no limit to visits, and yes at times I've required daily visits to stay out of the hospital which they approved. Unfortunately my shrink isn't on the plan, although I found out my therapist is and although she has to make monthly requests, they do provide unlimited visits with a $15 co-pay. My shrink is $200 (does therapy and meds) and I pay him out of my husbands pre-tax health contribution plan. take care, judy
Posted by Ted on November 12, 2002, at 12:26:29
In reply to Re: looking over therapist's/psychiatrist's shoulder » ShelliR, posted by judy1 on November 12, 2002, at 11:49:10
Hi Judy,
> I think the average insurance policy covers 20 visits/year except in CA (and other states) where they have parity for severe mental disorders- schizophrenia, bipolar, MDD, and panic I think.
I live in CA and I have what is considered by most to be "good" insurance and I will be the first to tell you it is FAR from parity with other medical coverage. Please see my above posts about INSURANCE HELL.
Now, if you do find someplace in which mental health coverage is raised to other medical coverage, please let me know. What I am afraid will happen if the congress critters in Washington meddle with mental health insurance parity is that other medical coverage will be LOWERED in quality to the current level of mental health coverage. They will have thus reached parity and by the easiest and least costly path.
I am often called a cynic, and I am just as often found correct.
Ted
Posted by judy1 on November 12, 2002, at 22:28:10
In reply to Insurance parity in CA? - » judy1, posted by Ted on November 12, 2002, at 12:26:29
Ted,
I have Pacificare- and their behavior health benefits spell out unlimited visits for severe mental disorders- bipolar (which I have) qualifies. I was under the impression that this was a mandated law in CA, but perhaps it is just my insurance. take care, judy
Posted by Ted on November 13, 2002, at 13:43:36
In reply to Parity » Ted, posted by judy1 on November 12, 2002, at 22:28:10
Hi Judy,
For 2003, I have a choice of PacificCare, UnitedHealthcare, HealthNet, and KaiserPermanente.
In HealthNet, it is unlimited, but the other medical coverage offered stinks.
In PacificCare, the plan offered is limited to 30 days both inpatient and outpatient.
Kaiser is limited to 20 outpatient days and 30 inpatient days.
UnitedHealthcare uses ValueOptions for Mental Health administration, and the VO plan we have is unlimited with in-network doctors (see my previous post regarding horrid in-network doctors with questionable business practices) and 20 visits max and 50% R&C refund (amounts to about 40% refund) with out-of-network doctors.
I also have bipolar disorder. I don't think that matters. And evidently, based on these 2003 offerings, mental healthcare parity is not mandated in CA. Maybe someday....
BTW: I chose UnitedHealthcare because the medical coverage is best. It works like an HMO with in-network doctors and like a PPO with out-of-network doctors and every doctor I have ever seen is in-network. :-)
Ted
> I have Pacificare- and their behavior health benefits spell out unlimited visits for severe mental disorders- bipolar (which I have) qualifies. I was under the impression that this was a mandated law in CA, but perhaps it is just my insurance. take care, judy
Posted by judy1 on November 13, 2002, at 17:19:23
In reply to Re: Parity » judy1, posted by Ted on November 13, 2002, at 13:43:36
A Snapshot of the
Implementation of
California’s Mental Health
Parity LawIn 1999, California passed a mental health parity law—AB88—requiring private health insurance plans to
provide equal coverage for physical health and selected mental health conditions, including serious
mental illnesses (SMI) in adults and serious emotional disturbances (SED) in children. The law requires
health plans to eliminate the benefit limits and reduce the cost-sharing requirements that have
traditionally made mental health benefits less comprehensive than physical health benefits. These
include higher copayments and deductibles and limits on the number of outpatient visits or inpatient
days covered.Ultimately, the expansion of mental health benefits under AB88 is intended to improve access to and
quality of mental health services for people with SMI and SED. Other goals of the law are decreasing the
financial burden on California’s public sector in providing mental health services, ending discriminatory
practices in the provision of mental health benefits, and reducing the stigma associated with mental
illness and the delivery of mental health services (California Senate Rules Committee 2001).
Talk to you HR person- good luck, judy
Posted by Ted on November 13, 2002, at 18:05:04
In reply to Ted, I knew I was right about the law » Ted, posted by judy1 on November 13, 2002, at 17:19:23
Posted by judy1 on November 14, 2002, at 0:11:14
In reply to Wow! Thanks for the info! -- (nm) » judy1, posted by Ted on November 13, 2002, at 18:05:04
Posted by bookgurl99 on November 19, 2002, at 7:35:17
In reply to Insurance Company Purgatory, posted by mair on November 8, 2002, at 16:56:08
Health care is a right, not a priviledge. It's only the mismanaged priorities of our government that lead you to believe otherwise.
Don't fear, the insurance company isn't starving --
Posted by mair on November 19, 2002, at 21:28:33
In reply to don't feel guilty. » mair, posted by bookgurl99 on November 19, 2002, at 7:35:17
You're right of course, but it still seems sometimes like an embarassment of riches. Several years ago I used up my lifetime cap and essentially stopped going to therapy - but my state passed a parity bill that applies to everyone, not just larger employers, like the federal bill. Now although I run into claims snafus, my basic coverage is so much better than most people's - I mean unmanaged care for mental health is becoming increasingly rare I think. So in a sense I feel that I've been given something of a gift that I shouldn't squander and that I must be squandering since I've been through so much therapy.
BTW - after my state passed a parity bill. it took the major insurer here (blue cross) a couple of years before they changed their literature. My written policy contained the same illegal caps for a long time, although of course the company didn't try to enforce them. I wonder how many people didn't even try to seek care because they assumed their policies didn't really give them what they needed.
Mair
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