Saturday, September 12, 2009

Taking it in the Rear – Part I

As evidenced by my last two posts, health care has been on my mind as of late, as it is indeed on many people’s minds. I can approach the issue from a philosophical standpoint and provide reasons why I believe the free market and competition have given us the best health care on the planet (despite its flaws), and why the last thing we need is more government involvement, which inevitably invites inefficiency and abuse, as well as the mediocrity and poor service that are inherent in a one-size-fits-all government operation.

But I also have plenty of anecdotal reasons to buttress my philosophical position, as to why the free market works and the public option does not. What follows is one of the few negative experiences I have had with the private system, but in the end it turned out okay. I posted this story last December at a blog called “Down with Absolutes”, where I served as one of the few conservative voices amidst a sea of lefties.


Oh, no! Another TMI post from Leo?

During the past decade or so of biannual checkups, my general practitioner had been warning my wife and me that, after we reached the half century mark, we should have a colonoscopy. So after I turned fifty this year, we decided to go through this rite of passage together. We called the gastroenterologist recommended by our G.P., and he arranged everything, pre-certifying the insurance coverage, and we were scheduled for back-to-back days at a nearby hospital.

Those of you who have already had the pleasure know that the worst part of a colonoscopy is not the procedure itself, during which you are mercifully under sedation, but rather the preparatory phase. This involves a day of fasting, with nothing but liquid intake the day before the procedure, including a gallon or so of a foul tasting solution specifically designed to clear out your intestines. Needless to say, this causes a significant deterioration to your social life and mobility, keeping you no more than two meters from the nearest bathroom.

Other than that, the procedures were uneventful. My wife drove me to and from my appointment the first day, and I returned the favor the next day. The only odd thing I remember was on the second day when the gastroenterologist informed me that everything went okay, and that neither my wife nor I had any polyps or signs of colon cancer, but he also added:

“You know, your wife’s colon is twice as long as yours.”

“Oh, that’s nice,” I wanted to reply. “And your point is?”

I wish I could say that it all ENDed there, but alas it did not. A few weeks later, I got a statement of benefits from my insurer indicating that everything was paid according to the amounts negotiated with preferred providers, EXCEPT the anesthesiology services. What?!?! (Actually, I had read somewhere that some insurance companies were starting to balk at covering anesthesia for routine colonoscopies, claiming it is not medically necessary. Of course, technically speaking, anesthesia is never medically necessary, but it sure is nice to have for most surgical procedures.)

I fired off a letter to the insurer, indicating that my physician had pre-certified everything. The insurer wrote back and said that (1) the presence of an anesthesiologist is not necessary, (2) the gastroenterologist is supposed to be trained to provide the minimum amount of sedation necessary, and (3) any charges related thereto should be part of his “global fee”.

“But I did not ask for the full services of an anesthesiologist!“ I protested. “I went to the procedure in good faith, believing everything was pre-certified. I would not have done this if I had known we would have to pay approximately $500 each out of pocket. We were just following doctor’s orders. It’s not that either of us was anxious to get a colonoscopy!”

During the next few months while I got repeated bills from the anesthesiologist, I tried a couple more direct appeals to the insurer, but to no avail. This past October, it occurred to me to write a letter to the gastroenterologist. After all, he was the one who arranged everything and called all the shots. I told him the onus was on him to either appeal and provide further documentation to the insurer, or settle up with the anesthesiologist himself. I cc’d everyone and their sister, including the anesthesiologist and the insurer. This apparently had the intended effect, because the insurer finally decided to consider an appeal and requested further information from the gastroenterologist and anesthesiologist, including an anesthesiology report. The former sent a letter stating the anesthesia was necessary because I have a “low pain threshold” (Far be it from me to argue with that, but it does sound pretty lame.) The latter sent nothing.

With that, I felt I was home free and could continue to ignore the anesthesiology bills and past due notices, until…. Early this month, I got a notice from a collection agency. Despite the fact that the insurance claim was still under appeal and the anesthesiologist still had not sent them the requested reports and documentation, they turned the account over for collection. I immediately called the collection agency and said I had no intention of paying the bill, and I certainly was not going to pay the $200 collection fee they tacked onto the bill for the wonderful “service” they were providing me! The less than amicable agent to whom I spoke advised that if I did not pay by January 5, the past-due account would show up on my credit report.

The other day, I fired off a nasty letter to the collection agency, again cc’ing everyone and their sister, indicating that the medical provider had no right to turn the account over for collection before exercising all due diligence to provide the information requested by the insurer. I further intimated I would take legal action if they did anything to inappropriately mar my otherwise perfect credit record. The jury is still out on what will happen next. Somehow, though, I think I am about to receive yet another colonoscopy.

Now you might be scratching your head wondering why I am posting this as an example. Isn’t this illustrative of how those evil insurance companies cannot be trusted, because they are only interested in making a profit? Indeed, Mike Matthews, the originator of Down With Absolutes, immediately replied: “Welcome to the world of for-profit health insurance, where health CARE is only an incidental consequence. Hope your appeal wins.”

That was just the opening I was waiting for, so I countered:

I was kind of hoping you would take the bait. Are you suggesting that I would have fared better under a nationalized health care system instead of being at the mercy of one of those evil insurance companies?

Actually, I am generally quite happy with my insurance plan, this latest surprise notwithstanding. If they are going to tighten up on the rules for what they will and will not pay for, it is their prerogative, as long as everybody knows up front. Whether it was the insurer that did not provide full disclosure or the medical provider that did not provide the necessary justificaiton and documentation, the jury is still out. But at least the insurance company has not closed the books on the issue.

The advantage of the for profit model is that, in the long run, it will keep the costs down. The alternative government run model might seem cheaper and more caring, especially when the costs are hidden in your otherwise huge tax bill. In the short run, the government pays for everything, no questions asked, because–unlike the private sector–the government does not have to worry about balancing the books, much less making a profit. In the long run, as reality rears its ugly head and the deficits pile up, government eventually raises the costs [while] the quality and availability of care …diminish. The perfect example is government’s first intrusion into the medical field: Medicare.

Any expansion of government into medical care is bound to produce the same result: Years of deficits, followed by reductions in service which make the private insurance companies seem generous indeed.

Oh, and by the way, the insurance company eventually agreed to pay the anesthesiologist after my many appeals. If my one and only insurer had been the U.S. government, to whom would I have appealed? In any event, all is well that ENDs well.

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