Inexplicable, Costly and Wrong; An “Extra” Blog

Okay, I defy anyone to explain this to me.

As regular readers know, I’m in the hospital recuperating from a nasty fall. I broke my pelvis and my clavicle. I’ve been here 8 days, although the doctors wanted to send me to acute rehab three days ago. (Acute rehab is apparently more intensive, appropriate for people who have been active and can be expected to respond to longer sessions of physical therapy–and thus leave for home more quickly.)

This morning, I was finally supposed to be transferred. But then, Anthem, my “insurance” company (note the quotes) rejected the doctors’ advice and denied the move. According to the caseworker, since the first of the year, insurers have been denying approximately 50% of requested moves to acute rehab. Without seeing the patients, without consulting with their doctors. The hospital can and does appeal, and about half of those “peer to peer” appeals are granted–we’ll see what happens with mine–but even the appeal process evidently becomes a game; calls are routinely returned after hours, for example, when the insurance company knows the physician won’t be available, prolonging the process.

But here’s what is insane: keeping me in the hospital costs more than sending me to rehab.

Why would a company that should want to keep costs down opt for a placement that (1) is medically inappropriate; and (2) costs more? Why did the approval process suddenly become more arduous at the beginning of the year? What is the larger game being played in which I find myself a pawn? And what therapy will Anthem pay for? Anything? Or is my 83-year-old husband supposed to drag me up the stairs at our home and help me in and out of bed when nature calls?

Tell me again how horrible single-payer systems are


  1. I am so sorry you have to deal with pain and suffering and then to add frustration about illogical decisions made for your care, but not by you, has to be maddening. I have been pleased to still “hear” your voice in your blogs and hope you have a speedy recovery and that the hospital will prevail against Anthem, and you will have the proper care.

  2. What Marie said! My health insurance company is no better than Anthem! Get well soon! Looks like you’ll have to do this by yourself.

  3. Sheila, repeating what Marie said…and this experience should supply you with plenty of fodder for upcoming posts…can’t wait to read them.

  4. Probably does not cost Anthem more due to large write-offs at the hospital whereas the Acute Rehab providers likely does not have such an agreement in place. Just because the bill you see may be larger doesn’t mean the paid amount will be larger.

  5. Very Frustrating …

    I arrived at IU-Health Neurology facility yesterday at 11:15am
    (for my 11:30 scheduled MRI) to find that IU-Health had not
    pre-approved me with My Healthcare provider (United Healthcare)
    After waiting around for 2 hours, we left without the MRI. As now
    my Healthcare provider decided to argue and dictate to the
    Neurologist, what type of MRI they would approve. (apparently
    I need one with Dye to reflect the dopamine levels in my Brain)

    Apparently, the Head Honcho at United Healthcare, earns $ 67,000,000.00
    per annum …

    I’ll echo the above

    “Tell me again how horrible the single-payer system are”

    Having lived the first 30 years of my life on the National
    Health System in England, I can attest as to where better
    healthcare is.

  6. It is a game and it depends on what type of dealings have gone on with the acute care settings. As a nurse for 20 years your doctor does not have control of your care it is the insurance companies that have total control. I worked in child psychiatry and psychiatry always has to appeal everything and I would spend hours chasing for appropriate care mostly on my own hours as the MD or clinic doesn’t get paid for chasing those dollars. I would get so mad and ask what degree the person telling me ‘no’ they don’t want to pay for Zoloft (at that time it was on Walmart’s $4 formulary) but would rather pay for Moban or some other medications that are a zillion years old and has a ton of side effects and completely inappropriate to put a child on….fyi…the people denying claims often do not have any degree and are just following some diagram.

    My old PCP (I just moved to Tennessee) has broken away and is on her own. She will accept insurance but you will have to file the paperwork. She is tired of being told what labs will be paid and what labs won’t be paid…labs that can help with further diagnosis problems. She is tired of being told she can only allow to spend 10 minutes with each patient to meet ‘business goals’….she is tired of having to hire more people to chase those insurance dollars instead of paying for nurses who could assist the extreme workload and provide much needed patient education in an ever more complex healthfield.

  7. Things get worse every year, but this year is markedly different, regardless of the insurance carrier. Everything that costs more than about $4 now requires a PA (prior approval). I see 20 patients a day. Every day, at least a few of my patients have at least one med, medical supply, test, or hospitalization that requires a PA. That means 20+ PAs per week. A few years I ago I used to do 1-2 a week, and 10 years ago they were only required for a very few rare things. A couple of common meds have been in short supply of late and their replacements are requiring PAs (e.g., albuterol inhalers). Every insurer now has its own formulary (preferred drugs), which changes about every January. When they deny coverage for a drug they don’t usually bother to tell us what is actually covered on their formulary. They refer us to their on-line site, which is usually out of date. So we have to make several attempts to find something that is covered. Every call takes a minimum of 5-10 minutes, and I have been on hold for as long as 40 minutes before hanging up to try again later. When they send a denial, they give us a phone number that is supposed to be for expedited service for physicians, but inevitably, when I call that number I am told I called the “wrong number” and am given another number to call. Oh, and that whole “medically appropriate” thing? It’s just jargon. It means nothing medically. They do not read or follow published standards. They cover what they cover and nothing more. And they do it in their own sweet time. Need an expensive antibiotic? Too bad. They have 72 hours (business days only) to get back with you, so don’t be requesting it Wednesday afternoon through Friday. Need PT? 6 visits only are approved. It doesn’t matter for what. At the end of the 6 weeks you can request another PA, but it’s a toss-up whether it will be deemed medically appropriate. Death panels? You have met them, and they are not the government.

  8. I understand your frustration. I’m sure the simple answer is that it’s all about the money. Last night I had internet trouble and was dealing w the telephone co./service provider; I was pondering how customer service had moved so far from its intended goal to becoming company-focused, low cost, little-to-no service. I had to repeat my telephone number, name, address, account number to each of the three reps I found myself talking to. It took over one hour w them to realize I was wasting my time and theirs. I told the last one I would do my best and call back if I needed to.

    My take away was the revenue money is spent on bonuses for corporate officers and advertising; the company really doesn’t care about the customers – only the customer’s money. Sheila, maybe you’re finding yourself in the same spot.

    Wish you the best.

  9. Insurance companies make money when they deny care. If that isn’t a recommendation for single payer I don’t know what is. Look at the senior executives make annually. It’s obscene. It’s all coming out of the medical care system. I’m sorry to hear you are caught in this mess

  10. Oh Shelia, follow the money…since insurance is all about finance and little to nothing about patient well being I’ll venture a guess big A has struck a ‘deal’ with local hospitals to fill beds, or the rehab joint is no longer ‘in-network’ because they didn’t want to take 25 cents on the dollar for their services.

    We too have Anthem and noticed this year them making it much more of a hassle to see and pay even those sanctioned providers. My wife’s annual was denied as “out of network” when it’s the same physicians group she’s always gone to and the doc is even listed on the A site with a handy big green check mark. I disputed the denial only to be refused again, even with screen shots of their own website included…AND other bills afterwards from the same group have been paid!

  11. I agree with Marie’s and Betty’s good wishes and sympathy, though I’m not convinced single-payer would really be any better. Maybe this is one of the trade-offs the insurers make with docs and hospitals to offset their acceptance of lower in-network payments on charges (even though I strongly suspect they simply jack up the charges so the new net is the same as the old gross). Anthem has been good about covering my husband’s PT bills once he came home, but I also suspect the amount and level of in-home care they’ll cover may be another ball of wax. Maybe your vaunted feistiness will help!

  12. I fell and broke my arm in Ireland. Two nights in hospital, surgery to align the bone and place a steel plate and six screws, anesthesia, EKG, pain meds, consult with rehab doc, etc etc …$5000. Which I wasn’t even charged till a month after I returned to the States. They didn’t even take my credit card number! About 4 months after I’d submitted the bill to Aetna, University of Galway Hospital billing called to ask if I’d received the bill, as they hadn’t heard anything from my insurance company. After calling Aetna myself several times and getting the run around about payment being processed, I finally discovered that my bill had stalled in the “foreign transactions” department, awaiting – GET THIS – translation! The letterhead of the hospital stationary is written in both English and Gaelic. The remainder of the 4 paged bill was in English. Stupidity? Or any ploy to keep from paying? And during this time my husband had a colonoscopy here in the States, in and out of the facility in a matter of hours. His bill? $5000.
    I’m so sorry you have to put up with such nonsense while your energy should be directed into healing. I hope the issue is resolved soon. Be well soon!

  13. They may just be paying a waiting game. Maybe they are thinking you will get tired of the hospital and go home hoping your husband and you can get by. But, be aware, Medicare/insurance will ONLY pay for rehab IF you transfer directly from the hospital after a FULL three day stay. So if you go home and you can’t make progress or it’s too hard, you are up a creek.

    I agree that customer service stinks. The problem is that CEOs and Board Members get bonuses based on yearly profit so their aim is to cut corners wherever, pollute however, etc…..not worrying a bit about the future. A quote I like is “We have enough for everyone’s need, but not for everyone’s greed.”

  14. I have spent untold hours on the phone trying to deal with my insurance company. And they haven’t even denied anything! They are apparently incompetent, or if not they are giving their member services people information that is not correct intentionally to make it hard to get benefits. I’ve been told (in early 2015, when the company was new in the state) that they don’t have any in network therapists, so just pick one and have them bill, told that twice (I was suspicious) before I took my teenager to a therapist who I knew was good, and when she billed after two sessions she was told she was out of network, so they couldn’t pay her. But when I called they said we could do a retroactive prior authorization (I should have been worried at that obvious oxymoron) and get the two sessions covered and more sessions – just have the therapist file the Prior Authorization. The therapist had trouble figuring out what she was supposed to do, so I called member services again and they said, oh, no, the therapist can’t file a PA, it has to be filed by the primary care physician. Every other time I talked to someone they gave me the other answer about who filed the PA. We finally got the PA approved (after both the therapist and the doctor submitted one, and I still don’t know which one was approved), and the approval arrived in mid June, dated June 10th (remember that date, and mind you this all started in March), and it gave approval for 6 sessions between March 3rd and May 31st.

    We were also trying to get some surgery taken care of. So being a good consumer I asked what I needed to do to find out what this was going to cost. They said that I needed the codes for the procedure and anesthesia and the estimated time for the procedure, the recovery room. The doctor proceeded to simply say that he wouldn’t give us that information. I got the codes from the office manager and I finally badgered her enough that he badgered him enough that he gave us what I am sure was a totally specious number – $22,000, just for his fee. This for a surgery that we knew we could get by paying out of pocket, including everything, for $5600. I had also asked about our deductible and max out of pocket. I was told that the family deductible was for family policies and the individual deductible was for individual policies, likewise for max out of pocket. This was contrary to all of my experience with insurance, so I managed to connect with an independent insurance agent who told me that it depended on the company how they interpreted it (the language was and still is ambiguous). So finally I was convinced, and based on our family deductible and max out of pocket we decided to just pay for the surgery, since we could have ended up paying up to $9000.

    2 months later I was logged into the insurance company’s website and found a page that showed deductible and max out of pocket, for both the family and for each individual in the family. When I reported that to member services, they said, with great assurance, “Oh, the website is wrong”. And I asked how they knew that the website was wrong rather than what they had been told to tell me was wrong. Since she couldn’t answer that question, she did a corporate escalation, which ended up meaning that I actually got to talk to someone on the other side of the firewall between member services and the rest of the company. And he told me that all they needed to tell me what the procedure was going to cost me was the procedure code. And also that the website was correct, and member services was wrong about the deductible and max out of pocket. I filed a grievance asking that the pay me the difference between what I paid and what I would have paid had on gone through the insurance, since my decision to go out of network was entirely based on the inaccurate information they had given me. Their response was that since the procedure was done out of network, they were not responsible for any of the cost, ignoring their part in the decision. I have now filed an appeal, and if that fails will file a complaint with the Indiana Insurance Commission.

    This year they are saying that what member services has as our Schedule of Benefits says that my daughter’s therapist is subject to deductible. The Schedule of Benefits that they sent me clearly states that the therapist is treated the same as the primary care physician for which whom there is no copay, no coinsurance, and no deductible. Since this was not a difference of interpretation but a difference on what the Schedule of Benefits actually says, I got them to do another corporate escalation. We’ll see what comes of this.

    Needless to say, yes, I am for single payer healthcare as well.

    There is more, but this post has gotten long enough

  15. I don’t know for sure how it is now, but years ago when my spouse was getting fertility treatments (we were very lucky that the state covered much of fertility treatment back then) they kept billing us for stuff that they were supposed to cover. I finally filed a complaint with the Indiana Insurance Commission, and whoa and behold, we were given a “Special Agent” to deal with all of our claims. Never had another problem! My bywords (see post above) have become, file the grievances, file the appeals, file the complaints! Wear the bastards down!

  16. Sheila; you are dealing with what I call “undertreatment”; not getting the proper care you need, have paid for and will be billed for additional amounts. My son and daughter-in-law have Anthem Blue Cross/Blue Shield with a $9,600 annual deductible; paying $520 monthly to the company plus all medical treatment and prescriptions till they spend that $9,600. I remember Bob’s health care when he became seriously ill in Europe; you touted the benefits of their Socialized medicine at the time.

    I have the IU Health Medicare supplemental (Plan C) which, due to no monthly payment or primary physician co-pay (and doesn’t that sound wondiferous!), they must depend on expensive, unnecessary medical tests and hospitalization to survive on the Medicare tit. A trip to Methodist ER resulted in hospitalization for heart disease; I had the flu and was severely dehydrated. The pissant ER doctor, several other doctors and nurses repeatedly asked me to describe my chest pains and difficulty breathing – each one received the same answer, I have never had chest pain or difficulty breathing. I was admitted to the hospital and numerous expensive cardiac tests were ordered. The doctors came to my room in groups; the assigned staff physician, a Hispanic woman, slipped me a note with my actual diagnosis. The cardiac specialist came to ask about my chest pains and difficulty breathing; he was not happy with my answer that it had never happened, not unhappy with me. The following day I was told by Dr. ER Pissant that more cardiac tests were needed and I would not be released. Thirty minutes later the cardiac specialist returned to tell me that day’s tests were all normal and I would be released. I handed him the note from Dr. ER Pissant (being deaf does have it’s advantages); he said I was being released that afternoon, signed the release papers and I escaped medical entrapment. The hospital scheduled a follow-up appointment with the cardiologist for two weeks later. He said my heart is healthy; all problems were caused by the severe dehydration from the flu. Told me to schedule an appointment for next year before I left the office; I asked, “WHY?”. He started laughing, said if I developed problems to contact him.

    We have learned from both ends of the spectrum why this system is called “Medical Practice”!

  17. I gave up on trying to understand insurance company “rationale” years ago. At 6:30pm, the night before my late husband was to be at the hospital at 6:30am for a hip replacement, we received a call from Blue Cross, our new insurer, saying his surgery had been denied as arthritis (the cause of my husband’s joint deterioration” was a pre-existing condition. Of course it was a pre-existing condition, but his orthopaedist wanted to delay the surgery until it was absolutely necessary. The rep then informed Ned that he should appeal. He did, and the surgery was performed a month later. The insurance company had to pay for duplicate pre-hospitalization tests and blood work. The entire system is insane.

  18. I so empathize with your frustration and bafflement. I’ve spent a total of months on the phone (and in court) over the past 13 years battling Anthem over my child’s care. At 5 he was diagnosed with a brain tumor. Anthem was perfectly willing to pay an anesthesiologist for all his MRIs, but declined approval for an $80 tube of EMLA in order to avoid putting him under for better than 40 of the procedures over the first 5 years. How healthy can it for a child to undergo general anesthesia that many times? One tube of EMLA got us through. $80 vs. who knows knows how much money…it is simply mind boggling. It’s been the same for medications needed for everything from his asthma to his sinus problems to his migraines. The company formulary rules. At 15 he was allowed to suffer for 12 solid weeks with his first migraine before a medication I asked for on diagnosis was allowed! And that had to be administered over 3 days/9 doses -headache gone by 2nd dose – in hospital. It used to be available in the US for about $0.70/tablet! Medication is now available in a nasal spray that costs $1500/eight doses so, of course, it took an ER visit and another hospitalization before Anthem would authorize his prescription. The inexpensive pills are no longer made due to “unavailable active ingredients” according to the FDA website where pharmacology companies report. I’m bewildered. The very same active ingredients are available for the nasal spray and suppositories that cost an arm and a leg. All that suffering, a semester of school down the tubes, and another job lost to caring and advocating for my child because Anthem’s profits weigh more heavily than what doctors and I recommend for his care. My best advice is to spend a gazillion hours on the phone jumping up and down, yelling, and insisting that they do what is best for you. Ask for a supervisor at the first hint of “no” and the supervisor’s supervisor when you’re told “no” again. The only patients who get proper care are the patients who demand it over and over again from the “Big Kids in Charge” of what’s allowed. All other patients serve only to mint money for the corporations in charge of our health care.

  19. After IU Hospital nearly killed me with Chemo and Radiation, I finally made it clear to all that I was leaving to go home — after about 5 weeks. The “experts” insisted that I go to a nursing home (where I would no doubt pick up MRSA and C-diff, Staph and who knows what. I said that I was going HOME. I could get a nurse to come in daily to check my blood work, empty my “Drains” (Which I can now do myself – several operations later) and report to the hospital. That was a few hundred a day. The Nursing Home would be at least 10 times that amount. My Insurance (ICHIA – That cost me $ 14,400.00 for one person per year) WOULD have paid for Nursing home, but I had to pay for home care all on my own. I am SURE I made the right decision to go home. Glad I could afford to do the right thing.
    Get well Prof K
    Do what you have to do
    I hope they understand they know how many lawyers you have on YOUR team 🙂

  20. So sorry you are being treated poorly by the insurance industry. It’s frustrating to be slowed by injury then $hat upon by bureaucracy. This is, sadly, the norm these days. The silver lining here is that you are spurring discussion and awareness, hopefully leading to change. The other minor happiness is that the food is likely better at the hospital. Hope someone brings you beanbags or something to throw! Hang in there, Sheila!

  21. I plan to say something nasty. I am amazed at the people who think our health care system is the best. I hear these yahoos and yo-yo’s cheering Ted Cruz or Rubiobot when they announce they will repeal Obamacare and not consider a single payer system. Has the part of their brain been removed that allows for cognitive, critical thought?? The system works some what if and only if you can afford it. If you cannot afford it go home and die or go into bankruptcy.
    What you see here is the enormous cost of system with all the people involved not in Medical Care but with pencil pushing, analysis paralysis, and bean counting. Think of all the money flowing to the pencil pushers. Think of the cost many companies incur trying to find heath insurance for their employees.

    One and only One Candidate for President wants Medicare for All and that person is Bernie Sanders.

  22. Why can’t insurance company’s be prosecuted for practicing medicine without a licence?

  23. I hope you are feeling better, but I understand that something like this can steal your peace and make you feel worse.

    It has been my experience dealing with insurance companies is that the required first response to any recommendation for treatment is always “No.” In your case the hospital and the doctor will fight for you and it will probably eventually be approved. What the insurance companies are counting on is that many people will simply not get whatever treatment is called for or in some cases will agree to a payment plan that leaves them out of it. DRGs will move them out of the hospital before they are really ready to go, but the standard of care for that diagnosis will be met. That way everybody gets their points from JCAHO and everyone is happy, except the patient, who really doesn’t count in the equation.

    There are lots of great arguments for the single payer system, but I’d be willing to bet it won’t happen in my lifetime.

  24. I am told that the members of the insurer’s review board (and their qualifications) are a matter of public record, and that you are entitled to that information. I’m also told that when you request this information the insurers suddenly become much more cooperative. Something about the reviewers’ high school degrees being trumped by actual doctors with actual medical knowledge, I’m assured.

  25. My wife fell and broke her jaw. She required reconstructive dental surgery. According to our policy Anthem covered accidents like hers. It was not covered, however, out of network. So Anthem simply did not add any of the appropriate oral surgeons to their network. In Indianapolis. So $20,000 later, we were simply out of luck. Not to mention the $10,000 in+ in annual family premiums. Anthem = SATAN. We will never do business with them again. Karma awaits them.

  26. @Richard Keefe: Because the insurance companies all have medical professionals on staff to cover that licensing issue. Medical care providers willingly abdicated their authority for everything but diagnosis to the insurers a long time ago, and now insurers are pushing back even on that, too. My own health care providers are openly frustrated with insurers now, but they have no one to blame but themselves for having let it come to this. The biggest barrier to good health care in the United States is the health insurance industry.
    Every one of us commenting knows others who can share personal stories like the ones told here, and those people know more people who can, and on and on. The only people who seem to have no understanding of it are those who are unaffected—typically the extremely wealthy or those whose coverage is provided by the government. The problems with the health insurance industry are so widespread that they can’t be addressed without dismantling an economic sector that employs more than 350 thousand people, not including contractors ( The only efficient cure is to go to a single-payer system where some of those people can find employment. But it won’t happen if we don’t all rise up together and demand it.

  27. @Steve Miller: If an insurer’s review board information is a matter of public record, why do you have to request it?

  28. Continuing best wishes Prof K. This one really created a storm! All told, it’s clear money is the main driver in our health care system.

  29. It’s a game to them and we are the suckers that have to play their game. Screw that. You know lawyers, get one on your case and pronto. They will act fast! Get well soon and I hope you don’t suffer much longer with their incompetence. All of these stories are exactly why we need single payer. Every last one of them.

  30. Sheila:

    Judging by the number and length of the responses to this blog, it appears you have hit a real hot button.

  31. Just one story of dozens I could tell: I have Anthem coverage through the Affordable Care Act Marketplace (“Obamacare”). According to the Act, all participating insurers must provide 100% paid coverage for an annual screening mammogram for women over 40. My health care provider uses two codes for the procedure: one for taking the films, and one for the radiologist’s reading of the films. In 2014, Anthem paid for the radiologist’s reading of the films but not for the films themselves. (Logic, anyone?) After 5 months fighting it, they finally paid it all. In 2015, I asked Anthem to tell me where I could go in-network that they would cover in full. They first told me that there was no facility within 30 miles where both films and reading of films would be covered. They asked me to submit an out-of-network referral form signed by my doctor. I submitted that, and they rejected it, saying that oh yes, there were places I could go in-network after all. Four months into it at this point and still have not gotten a logical response from Anthem. I can’t help but think there is a political agenda at work here.

  32. IMO, having private insurance, with the profit motive being the bottom line, drives up the cost of health care. Ages ago, when I was a small child and people didn’t need insurance to cover routine well child visits and immunizations, people could actually afford to pay for care. They had hospitalization coverage. Even then, hospitalization didn’t cost proportionately what it does today. Hospitals didn’t replace beds or other equipment when they reached the limit of their depreciation value, every little Podunk hospital didn’t have to have the latest nuclear medicine equipment, and hospitals even had people on staff who repaired torn sheets and patient gowns, rather than throw them away No advertising, no massive CEO, CFO salaries, no unbusy “satellite” facilities, either.

    Now, hospitals are like luxury resorts. Ever been to IU Health in Carmel? Absurd, outrageous, wasteful are words that come to mind, which descriptors also apply to their bills. Every year, costs and premiums go up along with CEO salaries. This will continue until enough people wise up and stop fearing a single-payor system like they have in Canada and England.

  33. I had a claim while in the Dominican Republic. Among the many delays in processing was United claimed that the claim date did not agree with documents. In the DR as in many countries, dates are written dd/mm/ yyyy rather than the US where it is written mm/dd/yyyy. It took repeated calls and emails to get this minor confusion straightened out. This was handled by the Foreign Claims Department and I can’t believe that this is the first time that this date format has arisen.

  34. My guess about what happened in your case is that more people were referred to Acute Rehab had to go back into the hospital, than were statistically optimum, so rather than look closely at who was failing and who was not, Anthem started denying the use of advanced therapy. Since people are the most expensive element in all businesses, they didn’t want to have to look at each case more closely, and thus the additional delaying tactic in responding to physicians.

    It will be interesting to know if you ever find out.

    As our excellent union rep once said, When you suspect a conspiracy, it is most likely incompetence.

  35. The insurance companies are practicing long-distance medicine and should be prosecuted for such. An In-house medical director who never sees or examines the patient should have their license pulled for this less than accurate medical recommendations. Our do nothing Congress is owned by the insurance companies and big Pharma.

  36. Now let me tell you about my $22,000 big toe. I developed a pressure sore on my big toe which became infected; I recognized it was infected but not sure how important the fact was. Before the family Christmas Eve dinner my daughter-in-law, a former Certified Nursing Assistant, looked at it and diagnosed a necrotic ulcer, yes it was important. Her mother arrived, a Certified Nursing Assistant, agreed with her diagnosis. When my granddaughter, a Registered Nurse, arrived they asked her to look at it; sure enough another diagnosis of necrotic ulcer. The day after Christmas my daughter-in-law called my primary physician who scheduled an immediate appointment. She reached the same diagnosis but ignored my information regarding 3 month earlier circulation testing of normal circulation except in my toes – which agreed with even earlier circulatory testing of normal circulation except in my toes.

    Doctor called a circulatory specialist to schedule an appointment for testing immediately. Away we go to the facility behind Methodist Hospital; 45 minutes of testing showed normal circulation (full body this time) except for my toes. We were told to wait till my primary physician had their test results; she was not satisfied and ordered us directly to the Methodist ER. Eight hours later, after ignoring our information regarding previous test results and undergoing more tests, a diagnosis of normal circulation except for my toes and…yes, it was a necrotic ulcer on my big toe. They coated it with bacitracin and a band-aid and gave me a referral to a Podiatrist. The bill for the circulatory specialist testing was over $12,000, the ER bill was over $8,000, the Podiatrist bill was $2,400. Of course Medicare received the major portion of these bills and no one understands why Medicare has been forced to cut back their payment rates.

    And Sheila cannot get the necessary transfer to rehab for two obviously serious injuries which could, if not receiving proper treatment, leave her in pain and possibly disabled. This is the way the system has always worked; the only difference is the skyrocketing cost of all medical care which began long before ACA was thought of and will be here long after ACA is better adapted or replaced.

  37. @Natacha: Agree with you. Health care should not be a private good like a smartphone or a loaf of bread. It should not be treated like a market commodity but instead like public education—necessary to the survival of our democracy.

  38. @EFK — because they don’t volunteer the information, hoping you don’t know it’s required and available.

  39. The first thought that came to my mind would be that your Anthem ins is probably secondary to Medicare, which means that Medicare is picking up all or most of your bill at the hospital. If transferred to a rehab facility, Medicare may only pay for a certain number of days and then Anthem might have to cover the entire bill. Without doing any research for you, this may be the reason. Ask to speak to the hospital administrator or at the very least to the CFO. You should be able to get an answer from them.

    Good luck with your recuperation – I didn’t realize it already happened 8 days ago.

  40. I lived in the Bay Area before moving to Seattle. I was a member of Kaiser Permanente. It was the absolute BEST! Now Kaiser is coming to the Puget Sound thru its acquisition of the venerable Group Health Cooperative. The transition period will take months but hopefully by next open enrollment Kaiser will be settled in and I’ll gladly switch back to it. No hassles, great online connectivity, no paperwork, and happy staffers and dedicated medical professionals. I can hardly wait.

  41. Wow, did you hit a nerve…so to speak! My guess is that we all have similar experiences. I highly recommend Steven Brill’s book titled America’s Bitter Pill to pass your time in recovery. Sub title is “Money, Politics, Backroom Deals, and the Fight To Fix Our Broken Healthcare System.”

  42. @Steve Miller: Right — and that is concealment, to my way of thinking, if there is a requirement for the information to be a matter of public record. What do the statutes say about the requirement to make review board information public?

  43. Health insurance went seriously downhill when they became for-profit. For years, insurance companies dragged their feet on paying for birth control pills even though the pills were much cheaper than pregnancy and childbirth.

    I’m SO sorry you and others who are battling pain, debilitating, and even terminal conditions must also battle insurance functionaries who overrule doctors to the detriment of patients and sometimes the company’s own bottom line.

  44. I’m too old and infirm to read all these postings. I will never be satisfied until we get single payer and do it without insurance companies (not in my lifetime, of course). Hillary knows more about it than anyone and she has the scars to prove it. Let’s see what she can stir up after January. I can’t say I would blame her if she doesn’t take it on in the face of a Fascist Congress. Hope is on the way but no Fascist Republican politicians allowed!!

  45. I hear people complaining about government healthcare. I have two government healthcare plans — Medicare and TriCare for Life — best coverage available. I have no respect for the private insurance industry.

  46. How maddening!

    Reading your collected tales, one thing stands out for me: one MUST be literate – aggressively literate – AND a skilled advocate in order to interact with the US medical system in any satisfactory way at all.

    So, what happens to the millions who are not literate, or unrelenting self/family advocates, or who have weaknesses in the myriad other abilities needed to actually receive benefits? As we know, the damaging effects of poverty and poor public education march on through the generations.

    Cynicism is an entirely reasonable response

    Of course you do know that this sort of medical humbug does not particularly plague the system in Canada, though thorough literacy and effective advocacy are not misplaced in dealing with our system either.

    Here is what it is like for one such as my aging self: Happily enough, everything I pay, including annoying but small medical plan fees, deductibles, drug costs, medical equipment, physical therapy, etc., and travel medical insurance comes to substantially less than $4000 per year. I do have an effective private plan ( through my retirement) which mostly covers drugs (due to my idiocyncratic medical issues). With what the plan pays on my behalf and the rest, as noted, I expect I am receiving/paying an average of less than (but not so far from) $10,000 each year. Of course there are years when the single payer system’s contributions are notably greater (if there are several specialists and/or hospitalizations, e.g.), but any negative effects on my personal financial security is limited. I believe that if I am so unfortunate as to develop cancer, that advocacy skills may become very necessary and this rosy picture regarding costs to me may dim somewhat, but it will not dissappear altogether and bankruptcy from medical expenses will never be in the picture.

    A friend who did die from breast cancer used to remark: if you hear people complaining about the medical system – sock ’em!

    Do not be surprized if you learn of an individual kissing the ground up here … As you can imagine, this sort of security makes every important difference. My health is currently very unreliable, but my constant concern is that I somehow give back some token (and, no matter what, it can only be a token) in response to what I receive.

    So, yes, other countries DO have demonstrably better ways of doing things.

    I am hoping, along with all of us who benefit so much from your generous sharing of your experience and thinking, that you, Sheila, have the shortest possible interaction with hospitals and PT and the rest and an even shorter period of pain and limited mobility. Best, best wishes!

  47. Never thought I would be saying this to a wealthy white lawyer, but welcome to the hood, girlfriend.

  48. IMHO it is how the insurance gets to its 86% of premium toward care. Just keep raising the prices of services and complicate the process even more. This way of course premiums will continue to rise with the cost of care regardless of how many are still uninsured.

  49. Having just gone through 3+ months of IUM Trauma Center, Major spinal surgery, Lutheran Hospital (3 3+day stays), failed Acute Rehab (billed for 3 weeks)and then very successful Acute Rehab (4 weeks after another 7 day hospital stay) and all the follow up visits with Medical providers, I look at the pages and pages of Medicare and United Health paperwork and go crazy. I am a responsible, competent, mathematical adult. I am the caretaker and advocate. But trying to track my husband’s medical needs and the billing and paperwork is a nightmare. I have yet to figure out the bottom line that we will owe. Scares the heck out of me.

Comments are closed.