How Do You Solve a Problem Like…Healthcare?

Next week I am scheduled for a baseline colonoscopy.  Though I admit to avoiding doctors whenever possible (I call it the “don’t get sick/don’t get hurt” theory) I also believe that certain screenings are worth their weight in gold, so next week I am scheduled for what I thought was a baseline colon screening.

Yesterday I got a call from someone at the facility where this test is scheduled to take place.  Apparently, when they checked with my insurance they learned I had a $250.00 deductible due the morning of the procedure.  Not a problem. Upon asking, the woman also told me I would be receiving 4 different bills after the procedure, representing the 10% I owed for each the physician, the facility, the anesthesiologist and the lab. I then asked Mitch to call our insurance provider to see why this wasn’t a covered screening since it’s recommended at a certain age, just like a mammogram.  I also remember paying all these bills after Mitch had this same screening about 2 years ago.  The phone call to Blue Cross/Blue Shield opened up a great big can of worms.

Insurance says if this is a routine baseline screening I should be covered 100% (of the agreed upon amount) for all aspects of the procedure.  I then called the facility back and they told me I had to talk directly to the doctors office because the doctor had put this claim in as a medical necessity as opposed to a baseline screening.  Made no sense.  Speaking with the doctor’s office, they enlightened me.  In my consultation with the doctor this past fall, I mentioned (when asked) that my sister had a few polyps removed when she had her first colonoscopy.  This statement, it seems, constituted some sort of family history that allowed the physician to code my screening as a medical necessity.  My guess is there is more money to be paid to the physician for a medical necessity than the agreed upon amount that would be received for a routine screening.  The very worst part of my conversation with the doc’s office is that I was told he won’t be in all week because he is on hospital rounds!  What, no cell phone?  No blackberry?  No email?  Are things really that bad for the doctor’s these days that they cannot afford to be reached?  Seems crazy that I can be, you can be, but they can’t be!?!?!

I am going to refrain from ranting, moaning and cursing because that is NOT what this website is about!  I will not name names, because that seems like such bad karma.  I am going to connect with my insurance company this morning and try to learn what constitutes family history as well as what my right is to a baseline screening that is covered by insurance.  Great questions suggested by my sister when I called her to vent.   I hope to then be able to share that knowledge with you.

Almost daily I am told stories of medical woes.  If you know me personally, you know this stuff infuriates me.   It’s no small wonder why our health care system is failing!!!  I have lots and lots of ideas about reform, but nobody has asked me.

Thanks for “listening.”  It’s important to me that my blog always has a point and it’s never just an endless ramble.  My friend Judi, who works doing billing for physicians, taught me years ago to always ask all the financial questions ahead of time.  Never assume anything.  You may have a procedure at a place that’s on your insurance only to find out the doctor isn’t.  Or vice-versa.  Or maybe the doc and facility are covered on your plan but the lab or anesthesiologist are not.  The possibilities are endless.

If you are like me and don’t care for surprises remember to never assume.  You know what happens…

I’ll let you know what I learn as this unfolds.  Have a great Tuesday.  Tonight is Biggest Loser!!!!

If you are local tonight is cardio fusion at 6pm and Pilates/yoga fusion at 7pm at Tamarac Fitness Center.  Come check one or both out!

If you know someone who is 65 or over, make sure to tell them about SilverSneakers.  Classes are taking place at a gym or center near you.  If you are in Broward County, you can find me tomorrow at Bally.  SilverSneakers classes at Tamarac Fitness will be starting in February and I will keep you posted on an exact date as it nears.