Contributing Works Stories

Insurance, Heal Thyself

by Debra Vernon

Recently, I experienced some abdominal distress which would come and go, but never entirely go away.  After one eventful morning full of pain and unpleasant side effects, I figured I had better have it checked out.  This is when I entered the world of “healthcare insurance hell” and it has been quite the journey.

If I go to a doctor for anything other than routine lab work associated with a maintenance drug I am on, it is a clear sign I am sick.  When I informed my daughter of my first office visit, she jokingly asked if she should prepare my final arrangements.  She knows if Mom is going to the doctor, mom is NOT WELL.

The healthcare which can be obtained in the US is top notch.  However, if you are blessed to have health insurance, convincing your carrier to let you partake of the healthcare services and/or products which can ease your discomfort and make you well is a job within itself, and not one for the faint of heart.  Luckily, the career path I have had over the last 30+ years has more than equipped me with the education and expertise to “talk the talk” of insurance.

Early on the first morning of this odyssey, I called my primary care provider (PCP).  I explained my symptoms and asked if it were possible to be seen.  There were no openings that day, so I opted to go to a local urgent care.  I did check to make sure the urgent care facility was an “in-network provider”, so my insurance would cover the cost.  They were in-network, so I arrived and was seen promptly.  Lab work as well as an abdominal ultrasound was deemed necessary and scheduled at the local hospital outpatient facility.  Lab work was scheduled right away, and the abdominal ultrasound for later in the afternoon.  Since the hospital is in-network, and there is no pre-approval process for either lab work or imaging, I was able to provide copious amounts of blood that morning and have the ultrasound performed later in the day.  Results of both tests did not clearly indicate the cause of my pain and distress.  I was advised by the urgent care to set up an appointment with my PCP to continue to pursue answers.

Now, it just so happened I was scheduled to see my PCP the very next morning for bloodwork.  I checked in at the window for the appointment, and explained what occurred the previous day, and asked if I could be worked in to see my PCP.  The person at the registration window looked for an appointment and explained I could be seen in mid-August.  I carefully explained I could be dead by then of an unknown cause and needed something just a wee bit sooner.  They said they could work me in the very next morning to see a Nurse Practitioner (NP), and I told them that was fine, and I would take it.  Meanwhile, after providing bloodwork and speaking with the phlebotomist about what was happening, she went with me to another scheduler and lo and behold, she was able to get me an appointment later the same day.  

I return to the office late in the afternoon and visited with the NP, who was very nice and listened intently to my spiel of symptoms and gave me a brief physical exam.  Her thoughts were to obtain a CT scan of the abdomen.  It was late afternoon, and their scheduler had left for the day, but the NP said she would make sure she had the paperwork and everything ready for the scheduler when she came in the next morning.  So, I returned home with a prescription for anti-nausea medication, with hopes the scan would be scheduled soon, so a diagnosis and treatment plan might be obtained.

The next morning (now day 3 of being more than just a little sick), I called the office around 11 am, as I had not heard anything.  When I spoke with the scheduler, she stated she was working with my insurance carrier on getting pre-approval of the CT scan.  I explained that my summary plan description (SPD) stated no prior approval was necessary for imaging.  She told me the carrier did say it was required for this test, and she was working on getting approval from them.  I thanked her for the information as well as her efforts on my behalf.  I believe the folks who work with insurance companies must be angels in disguise, as I know it cannot be an easy job to perform.

The next day was Friday, and day 4 of my misery.  By this time, I was ready to take treatment into my own hands by slicing my abdomen open, peering into the cavity, and yanking out anything I believed may relieve my symptoms.  The phone rang around 4 pm, and I was excited to see the caller ID of my doctor.  However, my happiness was short-lived.  Per the scheduler, she was still trying to obtain approval for the CT scan, but my carrier did not do their own approvals; they outsourced them to another company.  That company said I did not have a policy with the carrier so they could not approve anything.  The scheduler tried to appeal to them with the information on my ID card with the insurance carrier and explained this was now day 4 and the scan was needed ASAP.  They said they could only help once they confirmed I was insured and then it would have to be approved by medical review.  They anticipated this would happen in 4-6 business days.  

As you can imagine, this is NOT what someone who has felt like crap for several days wanted to hear.  I proceeded to enter “insurance mode” and started quoting verse and chapter of my plan document as it related to complex imaging.  I referenced the mobile application for my carrier which had the info clearly stated that no preapproval was required and explained it could be found on the carrier website as well.  I obtained a cell phone number for the scheduler and sent screenshots of both the SPD relating to the scan, as well as my insurance carrier ID card.  I was not rude, but I was firm in my response.  I could tell she was frustrated with the carrier as well, and with the information I sent, she promised to call them back.

While I waited for her to return my call, I was doing my own search for the preapproval company of my insurance carrier.  I did find a page dealing with changes made in 2019 as it related to preapprovals needed for imaging due to a cancer diagnosis.  But that was not the case here.  Someone at that company was not paying attention to the MD orders.

After a few minutes, the scheduler did call back with good news!  I did not have to have pre-approval (imagine that)!  But, since it was almost 5 pm on a Friday, she could not get a scan scheduled until the following Tuesday.  I was still ecstatic, as we were making progress, and I had learned how to alleviate some of the distress and discomfort.  I thanked her for her efforts and told her how much I appreciated her tenacity on getting me the help I needed.  

As I write this, it is the day prior to the scan.  I have some special vanilla-flavored contrast dye to consume later tonight and first thing in the morning (I’m sure it’s just absolutely yummy), and then the procedure will be performed.  Hopefully, it will provide the information necessary to find a treatment plan and get me back to feeling better very soon.

I have figured out my out-of-pocket expense for all of this after deductibles and coinsurance have been applied.  It is quite the chunk of change.  But I am still thankful to have insurance to help pay a large portion of the bills.  I am also appreciative of an MD office that works hard to help me obtain the care I need when I need it, as well as a healthcare facility close to home. But how much do you want to bet that when the bills start rolling in, I will have to review them for accuracy, to make sure they are paid in accordance with my SPD?  There is no doubt I will be on the phone, explaining to the insurance company what their responsibilities are concerning payment of my healthcare expenses.  Insurance, heal thyself – it is desperately needed.  

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