January 24, 2008

Spread the beef

Anyone who knows me, even remotely, knows that I have a huge beef with the American health insurance industry, which was greatly magnified after my own unpleasant run-ins with them over the course of the last two years. But of course while the insurance industry is certainly a ruthless predator and thus deserving much of the blame, they are not the sole culprit in sustaining what is a lousy health care system for Americans. A key player, I think, are American doctors, and I would now like to spread that beef patty of disgust to them, especially since they are now the one’s giving me problems dealing with the final portion of BCBS bill. The story is indicative of lager issues and problems that center on the problematic silence “spoken” by doctors.

To make a long story short, BCBS of NJ was not ponying up some serious cash (at least for me) for 2 mole surgeries because they were claiming it was pre-existing condition. After having the public relations director email me (thanks to that post) and a lot of research and letters etc, it was more or less resolved. Soon after they overturned the pre-existing “bs” (and I am not talking blue shield here), they promptly started to pay all sorts of bills (and I even got money back from doctors I had paid).

But there is one pesky $1600 bill that lingers like a bad smell and the question is why? I am not entirely sure but my interactions with my ex-dermatologists, Affilated Dermatology in NJ, I think reveal some important lessons as to why and how the medical establishment are complicit.

Basically, BCBS is telling me that it looks like they have been double billed because the cost is exactly the same for two procedures that are also exactly the same. I explained that I had did indeed have two surgeries on my scalp (they were really close to each other) and they let me know that the provider needs to call back and send information that clearly shows there were two surgeries. This actually seems somewhat legitimate and potential mistake (and it is not like medical billing is known for their lack of mistakes and integrity either).

So I call Affiliated Dermatology and while I would say they have been patient, in so far as patiently waiting for my money, they have been completely unhelpful in any meaningful sense to help me getting this resolved. Now, given how difficult it is to deal with the health insurance industry, I understand they can’t provide fine-tuned, fine-grained personal attention. The health insurance industry engages in some real hefty politics of foot dragging and well, there are so many foot soldiers at doctor’s offices to keep up with the web of knots that the health insurance constantly entangles us in. With that caveat in place, they can however do two things:

1. Inform you that you can contact the Department of Housing and Insurance and start some sort of formal complain process.

2. Give you some small clue as to whether the doctor has sent any of the additional requested information (they are usually mum, or enigmatic, or totally confusing with regards to that) so you know what the heck is going on.

So a few days ago when I was speaking with health insurance person at the dermatology office, she claimed there was nothing else she could do about this last bill. Every time she calls BCBS, she claims that they claim it is a problem with being a pre-existing condition, and I was like “how can that be when that has been cleared and every other bill, and there were many, has been paid?” And then she also said that there has never been this confusion before where 2 surgeries look like one, blah blah and blah (and in retrospect, I forgot to tell her that my double surgery, according to the doc, was in fact highly unusual, because they would usually do them on two separate days because they were so close to each other. They made an exception because I was literally on my way to Canada and begged them to do so but anyway).

Ok, so there I was bickering with this woman and feeling stuck between a rock and a hard place. Finally I let her know, point blank, that they have been remarkably patient with the billing but totally unhelpful in, well, helping me out. I let her know that they should let people like me know, for example, that they can file a formal complaint against the health insurance company and this would at least get the ball rolling. I then let her know that I had no other option but to file another complaint with the Dept of Banking and Insurance and they would just have to wait for that, at which point, she all of a sudden became more helpful. She suggested that we can do a three way call to resolve this. Well there you go. Why did it take a heated 15 minute conversation topped with a threat to get what I think actually makes perfect sense? Get the 3 parties involved on the phone with each other so as to all get on the same damn page about what needs to be done (not sure if BCBS will agree to this… at which point I will pester the public relations director again and in the end, I think this was resolved because he was sick of my emails).

Now, why why why why why why are doctors and their staff so unhelpful? I think that main answer is they are overwhelmed and don’t have the staff to deal with the enormous amount of foot dragging and coy tactics deployed by the health insurance. That said, there are 2 things worth mentioning that I think don’t paint a very flattering picture of many American doctors.

If you pay attention to your medical bills (and you always should), it is immediately evident that the doctors and hospitals get paid LESS, sometimes a lot less, if the health insurance company foots the bill because of the pre-arranged negotiated rate. So there is an actual incentive on that side of things to get paid via the consumer as opposed to the health insurance company. Now. I am sure that there are health care economic studies and reports justifying this strangeness but that does not make it right either. There is a clear incentive in place to get your green dollars, as opposed to those of the insurance company.

Second and this is a much bigger issue, is that I think that for any meaningful change to happen, we need the active support of a large percentage of the medical community, especially doctors. If they are mum, or actively opposed to health care reform (as was the case when the AMA helped derail the Clinton effort at instituting universal health care in the 1990s), well then it becomes all that much harder for the general populace and the politicians to initiate real change. Doctors are the ones, after all, with the moral weight and capacity to make claims that can STICK. If they are saying this system negatively impacts how we care for the ill, it is a system that is is immoral, well, one should listen to them as they are the ones, after all, who dedicated their LIFE to healing the ill, right? Yes? No? Maybe?

So their silence is nothing short of grave. The good news is that it seems like more doctors are on board than ever before clamoring for change in the right direction, but we need a lot more to come aboard…

A number of years ago, I wanted to write a controversial and critical article that claimed hackers are more ethical than doctors. I thought it would be fun to claim that those who are usually seen as ethical (doctors) are less so than those that are usually portrayed as bad-as* unethical tricksters.

Some people were offended by this because doctors deal with the great burden of life, death, sickness, and thus suffering while geeks and hackers are “just” geeking out on their computers. True. But at least a cadre of hackers have sustained a social realm and a real ethics–free software–in order to guarantee their own autonomy and also create the conditions for what is right for software.

Doctors, on the other hand, do not carry the torch of ethics as they should. While individually I am sure they deal with a oodles of difficult ethical choices and decisions, it is about time they they turn as a collective to the larger structural conditions that seriously cause a lot of harm to millions of Americans, especially the droves of uninsured. They have the moral weight to do something about it and it is about time they carry their weight in this battle and take some burden of suffering off others.


  1. The whole interface between doctors and insurance companies are crazy. I saw a doctor a couple of times at a local hospital, paid my co-pay and expected the rest would be covered by the insurance company. In this case, the insurance company was fine and sent the money, but for some reason the hospital created a new account for every single visit I made. Consequently, they had half a dozen accounts some of which had a surplus of money, some of which had none. Every two months I would get a new threatening letter from the hospital that they were going to send the bill collectors after me. I would call, the hospital on the phone and the accounts manager would say of just ignore that we’ll fix the accounts. It took four iterations of this process before the hospital somehow balanced my accounts out.

    The juxtaposition between the threat of the letters and casualness of the account managers surprised me. On one hand, we will wreck your life but oh don’t worry about it this happens all the time and don’t ask us to explain why we have this crazy system.

    Comment by Joseph Reagle — January 24, 2008 @ 7:34 am

  2. Geez. Yea, medical billing is a scam too. I recently got a bill from Columbia dermatology for a biopsy and they said the insurance did not pay. But they sent the bill to my old BCBS insurance as opposed to my NEW insurance, which I am almost sure came with the biopsy request. It is all fine (for now) but I have had bad medical billing problems and this is case in which the “good” folks at Affiliated Dermatology are doing their own foot dragging and I am livid. I have just spent too many biella-hours on this…

    Comment by Biella — January 24, 2008 @ 7:38 am

  3. Doctors do not charge individuals the same rates they charge insurance companies. Many documented cases exist of charging an insurance company several times more for a procedure than an individual; some of these cases specifically involve the same person, such as when a doctor’s office tells a patient that the insurance company won’t pay the $x for a procedure, but that the patient can pay for it themselves for $y (a much smaller amount).

    Also, you describe government plans for “universal healthcare” as “healthcare reform”; you actually think the government will have *less* foot-dragging and *less* bureaucracy? We badly need a better solution for healthcare, but that definitely doesn’t qualify. I think most of the problem comes from the issue I mentioned previously, that insurance companies can pay more; this leads to our current situation, where only insurance companies can afford to pay for healthcare.

    I often think we could solve the problem for good by simply requiring all healthcare professionals to treat first and deal with payment later; prohibit selection criteria that include ability to pay. Then, if you can afford to pay you must, but if you can’t you still get treated. Normal rules of triage apply, so this doesn’t mean every runny nose must get treated.

    Comment by Anonymous — January 24, 2008 @ 11:17 am

  4. Hi Anonymous,

    I see what is on my bill and it is clear that the health insurance company (BCBS in the past and United in the present) pay a negotiated rate that is less than what I would pay.

    About the potential for more red tape with universal health care, I don’t see it with the universal healthcare system we do have, Medicare. And to clarify, I am in charge of my mother’s health care needs and have been for five years so I have a lot of personal experience with. And it has been amazing to me HOW little red tape there has been. I have spent tons of time fighting private insurance but have spent a total of 10 minutes on the phone with Medicare in five years.

    Medicare pays and does so quickly and covers nearly everything. We would be bankrupt without it so I find it is a pretty solid and decent system.

    I am open to other suggestions but I think single payer sytem with some sort of supplemental insurance may be the way to go. I am also all for using NP, RN’s and PA’s to do a lot of the treating, not to mention we need more emergency care clinics that are not full blown hospitals to keep down costs.

    There are many nations where there is universal health care and their systems kick some serious butt in comparison to ours. Why not take the best of that and innovate some? It is surely better than what we currently have.

    Comment by Biella — January 24, 2008 @ 11:32 am

  5. Hunh. So the doctor’s office needs to confirm to the insurance company that what looks like a double-billing was in fact two separate surgeries.

    Would it have worked to simply write & print a letter to that effect for them, take it in, and have someone from the office sign it, and then send it to the insurance company? You could even have them print it out on their letterhead. Or were they unwilling to do such a simple thing, in which case… why???

    Comment by Karl Fogel — January 25, 2008 @ 1:00 pm

  6. Horizon Blue Cross of New Jersey has denied me benefits and wrongfully accused me of insurance fraud.
    One of their Senior Fraud Ivestigators claimed that I had duplicate primary health insurance.
    She also claimed that I forged medical bills from my doctors office for surgeries that I have had.
    How can this woman be called a “SENIOR” fraud investigator?

    Not only did I prove beyond a shadow of a doubt that I “NEVER” had the duplicate coverage-the doctor also
    verified that the bills for surgeries were sent directly from his office.

    When she couldn’t get me on these accounts, she made up tales that I was having an affair with the doctor and that all of my health problems were of a fictitious

    So, I now ask myself, how IS IT AT ALL POSSIBLE that this woman is still gainfully employed by Horizon Blue Cross when she plays HAVOC with people’s lives?????????

    “EPSTEIN” IS “INEPT”!!!!!!!!!!!!!

    Comment by Seriously Affected. — June 20, 2008 @ 10:12 am

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