A $16,000 Cup

We're in the middle of a battle right now. Not my partner against his illness - no, that battle is fought and nearly won. The real battle is Us vs. the Insurance Company.

A union man, J has never had to battle his insurance. I know a few other people who must have mega-insurance, because when I tell them about the incessant fights I've had on behalf of my son and (occasionally) myself, they said, "I've never had to do that." I envy them. I envy people who can go get an MRI when the doctor says they need one. Mine would have cost $930 - after insurance. So I didn't get it. Programs? Yes, there's programs. You can apply... after you get the bill. Don't qualify? Out of luck.

As most of my friends know, J was rushed to the hospital two months ago with symptoms of a heart attack. Fortunately there was no lasting damage to his heart - just a warning flare, they said. But while they were poking around in there, they discovered he has nine ulcers in his stomach.

Nine. It's a wonder that he didn't have soda squirting out on his chest every time he took a sip.

While he was in the hospital, J stressed about the money. Sure, he has insurance. And just like me and everyone else I know, he's stuck with the insurance his employer picked at the lowest bidder, because no human can afford insurance without your employer's help - at least, no one anywhere near my tax bracket. (Just for laughs? I tried to get insurance on my own when I graduated college. I was 23 years old and they wanted me to pay $900 a month on a salary of barely over $1100. And that was nearly fifteen years ago.)

I told J not to worry. Get healthy, then we figure out the rest. I knew we were signing up for war. And here we are. He spent one night in the hospital, plus a couple of doctor's visits, two procedures and a battery of tests. And it's the perfect example as to how this system makes absolutely no sense.

To date, the medical bills total nearly $16,000. I'll let that number sink in for a minute, because I have to go breathe into a paper bag when I think about it and how damn lucky we are it wasn't something like a car crash or a full-fledged heart attack. My father's attack a year ago totaled more than $100,000, but fortunately he has the Godzilla of insurance. If that had been me, with my insurance, you'd have to just let me die. Like I have $30,000 sitting around doing nothing.

They gave J a water jug at the hospital, so we could track how much water he was drinking. He brought it home and drinks from it at work so he's not tempted to drink the soda and coffee that worsens the ulcers. Also, it has the name of the hospital - which really did give him excellent care - on the side. We joke that it's his $16,000 cup. The most expensive cup we'll ever own.

Fortunately, J's insurance has processed... well, some of the claims. Enough to bring it down to a less-horrific $3,000 or so. This, however, is still beyond the capabilities of a couple with the combined take-home salary of the slaves that built the pyramids, particularly given the Boy's increasing appetite (does it ever STOP? Don't answer that.) Most are small bills that we will have to pay off one paycheck at a time... if we can get them to wait in line. It's a fight at every step.

But it's the ones they've denied that really hack me off. First of all: why is it that every separate person who gets near you in a hospital gets to send you a different bill? At this point I'm waiting for the janitor to send us his personal invoice. If any hospital declared, "You'll get one bill, and it covers everything," I'd list it as my personal preference.

We have a spreadsheet of bills and insurance payments and the copays we've made so far - keep in mind, this is for a 48-hour emergency that thankfully was far less serious than it could have been. We have nineteen separate bills at last count, including the hospital, the hospital's urgent care center, the hospital's cardio-cath lab, the hospital's outpatient wing (seriously? They couldn't just send one bill?), the ambulance that the urgent care center called after they saw his EKG, the pathologist, the cardiologist, the gastroenterologist, the emergency room doctor, the floor physician who oversaw his care and a partridge in a pear tree. (It's in there somewhere.)

They've denied coverage for an X-ray and all of his blood work, citing "out of network." Wait, the hospital is in-network. But the person who took his blood wasn't? And the person we never saw who ran the tests on his blood? What were we supposed to do, screen every human who came near him with a needle? "Excuse me, ma'am, I realize that he may be crashing with a myocardial infarction, but are you in the Insurance From Hell network? No? Sorry, then, he needs to sit here and DIE." It was an emergency room, for the love of Clara Barton! We're just lucky the nearest hospital to the factory where he works was actually in his network.

We're filing appeals on the denied claims. It'll take months. In the meantime, we've already gotten a collection call from the X-ray people. That conversation was fun.

ME: This claim was improperly denied and we've filed an appeal with his insurance company.
IT: Yes, but it's been two months.
ME: It's been two months since he was hospitalized, but it took more than a month for the claim to process in the first place. I have no idea how long the appeal will take.
IT: I'm sorry, there's no way to stop this from going to a collection agency unless you pay it in full.
ME: If we pay it, they'll never reimburse us.
IT: We could take a partial payment, but the rest would still go to a collection agency.
ME: We'd like to avoid that, as it'll hurt his credit rating. We are appealing the claim denial.
IT: I'm sorry, there's nothing we can do.
ME: Do you have a supervisor I could speak to?
IT: No, I'm afraid not.

So, no matter how that fight turns out, J gets a hit on his credit rating. That might matter more if we had any credit. We'll call that one a draw. At least until tomorrow, when I call back and ask someone else for a supervisor.

There's also the passingly important part of getting J healthy. His doctor put him on a stomach medicine, we'll call it O. He takes 80 mg a day. It's been doing a good job, he feels better and he's starting to heal. He's filled it twice and went to order another refill - this time a three-month supply, following his insurance company's guidelines for ordering maintenance prescriptions via their mail-order service.

Denied. Why? "This medication requires preauthorization."

Step up, it's time to fight. We strap on the boxing gloves. This medicine didn't require preauthorization the first two times we filled it. Why now? They tell us he doesn't have a medical condition requiring it.

a) I love it when insurance companies decide they know better than the treating physician what is or is not required for treatment.
b) Did you morons miss the $16,000 in bills you've processed in the last two months for his nine ulcers?

Our Doc rolls his eyes and files the preauthorization form.

Denied. Why? "We want you to take R instead. It's cheaper."

See (a) above.

Keep in mind, the insurance company isn't talking to the doctor. The insurance company talks to us, we talk to the doctor, the doctor talks to us, we talk to the insurance company. It's a game of Telephone designed by the Marquis de Sade.

We go back to Doc and he says that J can't take R (pardon the shorthand), it won't do anything for his ulcers. So he gets out the "Yes I Really Meant It" form and sends that to the insurance company. If I were a doctor, I'd find it really insulting that that form even exists. "Well, I prescribed that medication but I was just kidding. Now that I know it's expensive, he can have M&Ms instead."

Denied. Why? "There's an over-the-counter equivalent."

Why, yes. Yes, there is. At one-quarter the dose. We do a little investigating and find out that in order to get 80 mg a day of O, he will have to take four pills of the over-the-counter equivalent - twice as much as recommended, therefore off-label.

Then let's talk money! The generic Wal-mart version costs $18 a box. At four pills a day, he'd need a new box every ten and a half days. So instead of $10 for a three-month supply (which is admittedly an awesome deal), we'd be paying $162, which is way out of our budget. Plus, we can no longer use FSA money for a prescription.

Screw all this! we declare. Screw the Insurance From Hell, we'll just buy the damn prescription outright. How much could that cost?

$300 a month. Generic.

No wonder Insurance From Hell is throwing such a fit. I had a little choking spasm when I heard J repeat that number incredulously on the phone.

Doc has a helpful suggestion: cut it back by half. Take two pills a day on-label, 40 mg. See how that goes. Maybe the ulcers have healed enough that he doesn't need that much. This still means $54 a month, but we'll pretend that doesn't matter as we sing and dance our way to the poorhouse.

J lasted a day on the lower dose. Pain. Heartburn and nausea, of course, but actual pain as well. The language I have for the people who think his pain is an acceptable cost of doing business cannot be repeated in polite company. It was the weekend, so he doubled back up to four pills and made it through until we could call Doc again.

It's an ulcer. (Well, nine of them.) It's not life-threatening - unless you ignore it or fail to treat it properly. You want one that's worse? A friend of mine is going through a similar battle of stupidity, nine rounds with an Insurance From Hell, only the treatment she's fighting over is her mother's goddamn chemotherapy and while they wait endlessly on the appeals, the treatments have stopped and her mother has lost whatever ground she was making against her cancer.

And when it's cancer on the other side of the ring, people, you need all the help you can get.

Today, J told Doc that the experiment was a catastrophic failure. Doc swung into gear - I think he had to file yet another "Yes I REALLY FUCKING MEANT IT" form with the Insurance From Hell.

And that is how, on Round Six of this particular bout, we won. Insurance From Hell opted to pay for the damn scrip and he'll get his meds. And then I'll start taking that over-the-counter stuff, because I think all this fighting is brewing an ulcer for ME. Did I mention that we have nineteen of these bills?

The lesson in all this is that in order to get the coverage for which you are paying an ever-rising premium each paycheck, you have to fight. You have to appeal and appeal and appeal, ask to speak to supervisors, read the fine print and don't take no for an answer. J said until this, he never knew that you could fight an insurance company and win. And I wondered how many people didn't know you could fight at all, that "claim denied" does not have to be the end of the conversation or a one-way ticket to bankruptcy - or, in the case of my friend's mother, death. 


Sure, not every claim is supposed to be paid. But to ask a patient lying in an emergency room to refuse treatment because the person holding the needle might work for a hospital subcontractor that isn't a participating provider on your insurance plan is the height of venality. If my car insurance company or renters' insurance company provided this kind of service when I had to file a claim, I would immediately seek another insurance provider. That's why my car insurance company treats me better than this - they know I have a choice. I can fire them.

What happens if I fire my health insurance?

A $16,000 cup.