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Elder
Member Since Oct 2007
Location: Midwest
Posts: 5,042
16 1 hugs
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Jun 14, 2010 at 05:58 PM
#1
As many of you know my husband has been having some health issues. We still haven’t gotten to the bottom of it but a recent “explanation” of benefits makes me think I’ve some how gotten lost in the Twilight Zone.
We used to have absolutely wonderful insurance. It paid 100% of the bills period. There were no lists of acceptable providers, medications, or treatments. Several years ago the company my husband works for decided to have a new administrator take over, Humana, to reduce costs. Since then we have to jump through hoops to do anything. Due to my husband’s symptoms, his doctor suspected colon cancer and recommended a colonoscopy immediately. My husband called the 800 number, explained what his symptoms were and asked if it would be covered. The “customer specialist” asked where the procedure would be taking place, who would be doing it etc. She checked and all of the medical personal and hospital were all on the list and the procedure would be covered in full because we’d met our deductible for the year. The “explanation” came in the mail and it stated that we would have a $1,200 co-pay. My husband called and was told “because the procedure was medically necessary it was in a different category and therefore not covered 100%! When he got off the phone, he came in and explained what happened and I thought surely he’d gotten something wrong, so I called. Nope, because it was deemed medically necessary we had a co-pay. I tried to remain calm and explain that we’d called before the procedure and were told it would be covered. The “customer specialist” (whoever titled this job definitely has a sense of humor) explained that the person we spoke to previously did not understand that it was medically necessary. She kept saying that over and over! Who has a colonoscopy if it isn’t medically necessary?!?! Who walks into a doctors office and says “hey, I’m bored and want to drink a horrible concoction that will give me extreme bowel issues for the next two days, sign me up?” Isn’t the point of having this type of administrator to ensure that we’re not getting unnecessary tests and procedures? What I’ve learned is that they’ll pay for it as part of a physical or something, but if the doctor discovers polyps and burns them off the procedure is then no longer covered. This is not what happened in my husband’s case, so we’re seeing what we can do to have the hospital deem it “routine” rather than “medically necessary”. __________________ I've been married for 24 years and have four wonderful children. |
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 (JD)
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This is an old thread. You probably should not post your reply to it, as the original poster is unlikely to see it.|
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