Tuesday, September 28, 2010

The Strange "Logic" of Health Insurance

I recently had a cancer scare. It's OK, it didn't turn out to be cancer (as far as they can tell), but we had a tense couple of weeks until we found that out. I thought all that was behind me until I received the bill. Yes, I have the best (read "most expensive") health insurance that I can get through my employer, but they use pretzel logic and who knows what else to determine what they'll actually pay for.

In my case, I found a lump in my breast. Big lump. Painful. Obvious. So I went to the breast imaging center to have it checked out like you're supposed to do. My insurance paid for the diagnostic mammogram, which didn't detect the big obvious lump. They made me pay for the ultrasound exam that did actually verify that I had a solid mass. O-kaaaaayyyy, whatever.

Standard procedure in my case called for a core breast biopsy. Again, my insurer kinda sorta stepped up to the plate. They paid for everything involved with the actual procedure involved to obtain the necessary tissue samples from the breast lump. And then proceeded to charge me for the full cost of the pathology test. The whole point of the procedure was to obtain tumor samples to test for cancer, and they decide to pay for the extraction of the tissue but not the test?!? That makes NO SENSE at all. WTF? Do they not realize that paying for cancer treatment would FAR surpass the cost of paying for an early detection biopsy? Apparently they do not give a crap.

It wasn't all that much money out of pocket, but the principle of the thing bothers me. If something serious happens, just how much would they really pay for? Makes me wonder.


Jeni said...

I think in my recent posts I have mentioned my oldest (first) cousin and I are both cancer patients now and she and her husband have pretty much identical insurance to mine -same company, just slightly different name to the plans for her area of PA and mine. We phone back and forth usually at least once a week to compare notes on how we're feeling, treatments, legal junk about our homes and kids when we die and yes, about insurance and what they charge, what they pay. And we've decided it is all craziness!
She got a statement the other day -I got one similar to it too -about our chemo charges etc. Neither of us is sure what the hell either of these statements mean but she's now been told it is going to cost her $300 per chemo treatment now or very near future. The hospital where she goes charges a huge co-pay before being admitted there -mine, none nor did any of the hospitals I was admitted to in Pittsburgh. My bill for the 5 days I was in the hospital in early August for the surgery came to over $80,000! That's $16,000 per day and that is absolutely insane plus, I also had to pay for the tv in my room but at the local hospital, the tv comes with the room and much lower costs -much! -all around too. And to think that there are actually some people in this country who see no problems with our health care system. Now that is crazy too isn't it? All of it is a huge "go figure" me thinks!!
And I'm really glad to hear your scare turned out to be just a scare and not the real deal, Kiddo!

LL said...

Sorry... no help from this quarter either.

fermicat said...

I could have appealed their idiot decision (they sent me the paperwork to do), but it wasn't enough money to go through a process that would be sure to irritate me and be a big hassle. This isn't the first thing they haven't covered. Some of the routine labwork my doctor orders isn't covered, but I respect her opinion that it is important and pay for it out of pocket.

Jim Donahue said...

Semi-unrelated, but I had an absurd to-and-fro with a hospital over an ER visit that I never even made. Doctor must have put wrong SS number down or something. (I had been there a month or two earlier after a small accident, so I was in their computers.)

This took several months and many hours worth of phone calls to straighten out. Eventually, the woman from the billing department called and said with amazement in her voice, "Well, it appears you were never here!"

Incidentally, there appears to be a insurance rate for an ER visit which is more than what a person walking in w/o insurance would pay. My insurance company wouldn't pay because I told them I hadn't been there. The hospital wanted me, personally, to pay the higher insurance rate because I had insurance, rather than what a no-insurance person would have paid.


PS: Glad everything worked OK health-wise!

fermicat said...

Wow Jim, that's messed up.

fermicat said...

Got another letter from my insurance company today. Apparently the stuff they "cover" is only covered 90%, so I can expect yet another bill from the breast imaging center. *sigh*

Why can't they be man enough to just bill me for my part up front, ONE TIME. How long are they going to dick around with sending a bill for this and a bill for that?

BC said...

Im glad you are ok. Im sure it was a big relief. But always go with your instincts and get a second opinion if you need to. The last time I had a mammo, I had to do it three times because they said they detected something. So the third time, I went to a different place and they were able to confirm that there wasnt anything there. I have since gone back to the first place to have the ultrasound and there isnt anything there.

My old insurance sucked and I had to pay for some stuff out of pocket. My new insurance is really great though. They pay for everything except the copay and there isnt a cap on the Rx either. The old one capped at $1000 per year, per person. My daughters medications ate that up in two months.