These stories are true:
A middle-aged woman has Blue Cross Blue Shield (BCBS) health insurance which she has carried for many years. Over 25 years she slowly but steadily gained weight. Due to her obesity, she developed high blood pressure which led to impaired kidney function. She also developed high cholesterol and type 2 diabetes.
She lost 45 pounds. Once thin, her blood pressure and all of her blood readings returned to normal. Her kidney function, though sill impaired, improved greatly. She kept the weight off for two years before slowly putting it back on over the following three years.
That was ten years ago. Since then, as she has gotten older, losing weight has become more difficult (if not impossible) and all of her bad conditions returned. Her doctor told her that statistically, she was a candidate for heart disease and/or a stroke. Also, because of her increased weight, she now had difficulty controlling her diabetes as well, making her prone to possible blindness and amputations in the future.
She was motivated to lose weight again, but her hunger always won out. She tried every diet she could get her hands on, but being older, nothing seemed to work. The she heard about a prescription medication called Phendimetrazine.
She asked her doctor for a prescription. She was overjoyed when he agreed to prescribe it, and couldn’t wait to get started. Her level of motivation shifted into high gear as she dropped the prescription off at her local pharmacy for next day pickup.
To make a long story short, BCBS would not approve of the medication, stating it was “not medically necessary”!
She decided to pay the US$40 a month herself. Since then, she has lost almost 50 pounds and once again, her blood work, blood pressure, and diabetic blood sugar levels have returned to normal. Her kidney function also has improved dramatically.
BCBS evidently believes that co-paying for a prescription to the tune of perhaps US$20 or even $7 a month is to be avoided, but having pay out tens or hundreds of dollars for a triple bypass for some chronically obese person is acceptable!?!
Then there’s the guy who, after working for the feds for 35 years, carried his federal employee health benefits (he pays 33%) into retirement. He developed cataracts in both eyes. During the initial pre-surgery examination, BCBS refused to pay the $30 fee for part of each exam, the pre-surgery refraction of each eye.
Each eye required a standard 12-minute procedure. He wanted both eyes done at once, but was informed that the insurance companies only pay them half the fee for the second eye if both are done at the same time.
Although available, the man chose not to have any general anesthesia, since the eyes would be numbed up by drops and gels anyway. Each eye was done, two weeks apart, with no general anesthesia required or given. Identically.
When the man received the “Explanation of Benefits” (EOB) from BCBS after the first procedure, there was (quite appropriately) no claim made by any anesthesiologist, and thus none paid out by BCBS. So far so good.
When the EOB for the second surgery arrived, it showed a claim made by the anesthesiologist for US$570, and a BCBS payout of $348!!!
The man immediately called the surgical center about this. He was informed that they have nothing to do with the anesthesiologist, who works for a different company. He then called that company, and got nowhere. So he called BCBS to complain.
It took a dozen phone calls to BCBS offices to finally connect with their investigative unit. Two months later he received a formal response from BCBS. It said that the doctor had mentioned that a topical anesthetic (eye drops and a gel) had been applied and thus the claim was valid.
It neglected to mention that the drops and gel were administered by the regular surgical center staff, just as during the initial eye examination, and not by the anesthesiologist.
Further research (not mentioned by BCBS) also revealed that doctor had requested that the anesthesiologist “stand by” in the operating room “just in case” for both 12-minute procedures as a standard precaution. There was no mention of a fireman standing by “just in case” of a fire, or a policeman standing by “just in case” of a burglary. There was no mention that the anesthesiologist during the first procedure ethically didn’t submit a claim (for doing nothing).
Finally, the $570 claim ($348 paid) charge for doing nothing is actually the same fee as for full administration of sedating anesthesia and constant monitoring of the sedated patient, from before surgery until waking in the recovery room. The logic in that is…..?
No wonder the American health insurance industry and their conservative political big business protectors are fighting so hard to protect their profit margins. With stupid financial decisions like those listed above, they really need to keep what they have going. And what they have going, despite the penny-wise, dollar-stupid so-called “medical” decisions they make, is enormous record-broking profits year after year!
And by the way, at the rate of $348 for twelve minutes of doing nothing, the anethesiologist was earning her money at the rate of $1740 an hour!!
Hey, can I have a job like that?