Insurance Company "Logic"

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”.

Wow. That's quite a story. It's a darn good reason to have a single-payer, government health insurance authority. Profit-making health insurance companies are an oxymoron. Profits have to come from somewhere, and in this case they're coming from you and your husband. If this is your husband's employer's insurance carrier and your husband isn't in a position to get another job, there's not all that much that can be done, other than appeal after appeal within the insurance company process. My prejudices are showing in this post. I hope I don't get zapped by the admins for taking sides.

It is likely that your husbands company had to switch coverages because 100% paid for is no longer realistic in this day/age.
I help large companies put together their whole benefit package, I've been an insurance agent for 11 years.

Who ever told you there are more copays because it is medically necessary is being missunderstood or they miss-stated. When ever there is a hospitilization it is subject to deductible/coinsurance. There are scarce plans that still pay 100% for hospital but they are almost all HMO's.
Of course plans vary per state, I can't speak on behalf of all states. But given the circumstances you have above if he has a colonoscopy for colon cancer which is quite serious $1,200 is actually little to pay if you look at the whole bill.

I am not saying you should not be frustrated with the customer service reps. These are usually entry level people they hire & they do not always give the right answer. We have a joke in the insurance industry, don't like the answer you got? Call back & see if you get a different one.

Today a rich plan is $250 deductible & 90% coinsurance (in-network) 90% the insurance company pays & 10% you pay. A typical plan is more like $500 Deductible 80% coinsurance. My plan (I'm an agent!) has a $1,000 deductible & 80% coinsurance.

I understand going from 100% to now having a lot of cost shares is frustrating. But our healthcare is out of control expensive right now & it sounds like your plan is pretty rich in comparison to what I see every day.

I hope I helped some. Good luck.

I have worked for several hospitals in billing and insurance verification. Just for future reference, when calling to pre-authorize/certify a procedure, one of the things is not to discuss your symptoms only the procedure needed, doc and date of service and to verify your coverage. Otherwise it can bias the coding when it comes in. Also, you have grounds for an appeal if you documented the date, time and person you spoke with who said it would be covered. Doesn't mean it will go through but it is worth pursuing.

Contact the doctor office first to get help redirecting the billing to routine. It may not be possible unfortunately but they can be they can be your advocate. However, they may still consider it medically necessary unfortunately.

Good luck.

That really does stink AAAAA. I hope the results of the procedure were not positive.

We have a $1000 deductible and 20%. We pay $400 a month premium as well. It seems like nothing is really covered and all of our bills are very large.

WOW. I'm sorry you're having to go through all those hoops. We learned, too late, that Humana is one of the worst in the country! (Learned it after they let my dad die.All the doctors and nurses THEN told us.) If it weren't for Government subsidy monies, they would have been out of business eons ago!

Make sure the boss knows the struggles, if they hear it from enough employees (or get concerned about their own health care) they might change it again at open season!

Good wishes!

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For clarification purposes, our insurance would have covered the procedure 100% had it been “routine”. Since my husband was having issues (colon cancer was suspected) the procedure was considered “medically necessary” rather than “routine”. There are different co-pays for different categories. Based upon his age and medical history, a colonoscopy would not be unheard of for a yearly physical.

Also, the company my husband works for is self insured, Humana just manages the bills. The last HR director took these complaints very seriously, he and our company in general took a great deal of pride in their insurance coverage. He was on the board of our local hospital and a mistake in billing either on the part of the hospital or a miscommunication with the insurance company was taken care of immediately. We didn’t even have to call anyone, just bring him the bill and it would be corrected before the next billing cycle. Unfortunately he retired a couple of years ago and word seems to have gotten out that you don’t have to answer to Z anymore.

The customer service representative that I spoke to was able to see that my husband pre-authorized the procedure. Based upon the information this third person (1st being the one he called to pre-authorize, 2nd being the one he spoke to, and 3rd being the one I spoke to) was able to access, she surmised that the proctologist must have done something during the procedure to change the category from “routine” to “medically necessary” (her exact words), such as burn off polyps, which was simply not the case.

The medical field in general irritates me in general. The medical providers get to hide behind “we bill your insurance as a courtesy to you”, so if they make a mistake, there is no financial responsibility. The insurance company is on crack. The “reasonable and customary” costs between the doctor and insurance companies are a world apart.

The last insurance company we had stated that the “reasonable and customary” cost of a dental cleaning was $10 and they paid 90% of that. I told the customer service representative that if they could find me a dentist in the entire US that would clean my teeth for $10 I wouldn’t even use their insurance.

Haha about the dental insurance!

I seriously don't get the medically necessarily thing making it not covered. Seems like it would be the other way around, especially because docs love to order tests that are just random because they get some money from them. I don't know how this all works, but is there some recourse for you? Like can you file for a "hearing" or something to see that you did get it pre-authorized?

The quickest and easiest way to fix it right now is to have the billing department change the coding. The price of the procedure remains the same, but the coverage is different. If that doesn’t work then the next thing to do (although probably not the proper thing) is to contact HR. Like I said, this company is self-insured so they have a bit more control than a company that pays a premium on our behalf as part of the benefits package. It’s a long, complicated, and stressful process that we haven’t had to deal with in years.

Good wishes on getting them to work with you.

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