I sure as hell do. I just spent several days trying to line up my yearly mammogram and a chest X ray my doctor wants me to have—to no avail.
“Oh, my office doesn’t take your carrier, so you have to go have these done up in Assboink, NJ.” I explained that I do not have a car, so he did a bunch of paperwork so I could have it done in Comical Corners, a 45-minute walk away. I call the Comical Corners Imaging Center. “We close at 6:00 weeknights, so you’ll have to come on a Saturday. We can schedule you for an X ray in three weeks—but no mammogram for a month.” Oh, and now I not only need a prescription from my doctor, but a “referral,” explaining why I have to go to Comical Cormers and not Assboink—otherwise they won’t take me. I finally threw up my hands and cancelled the whole deal. If they want me dead that badly, I don’t want to disappoint them.
I’m not even going into the time my HMO wouldn;t pay the hospital when I had a spinal injury. “Pre-existing condition,” they called it. “Well, if you hadn’t had a spine, this never would have happened in the first place.”
Yes, I know it’s worse in the UK, where a friend of mine had her surgery cancelled three times (on the day of the operation!). And I know it’s worse in third-world countries where you just crawl into a Dumpster and die.
But, jiminey! why do these damn HMOs make it as difficult as possible to get anything DONE?!
I had to switch HMO’s because my old HMO decided not to do business with my company (for no reason). My blood-pressure medication is not on the new HMO’s formulary, so they won’t fill my scrip. And they can’t/won’t tell me a comparable med that is on the formulary. So now my doctor’s fighting with them, trying to get my meds.
The good thing about the HMO switch, is that I got to switch doctors. My old doc wouldn’t even examine me after I injured my neck and back in a car accident!
The OP makes it evident that we’re talking about health plans here, not homeowner’s, automobile, income protection, or anything remotely resembling real insurance.
Well, I don’t hate my health plan povider, either. I can’t figure out if that’s because it’s run by scrupulously honest and moral clairvoyant geniuses, or because those who complain invariably have Swift & Scrooge LLC for their HMO.
But, I go to my neurologist, and pay USD 10 co-payment per visit (the biggest problem that I ever had was with a receptionist with the intelligence of celery – “But your co-pay is only ten dollars, and that’s a twenty dollar bill!” Really. The neurologists should have hired her as an educational display, not as a receptionist). I take two prescription meds: the one that costs KUSD 8-12 they cover, the one that costs a tenth of that I pay for out of my pocket.
Possibly my reputation precedes me (I’m the guy who once called his landlord’s manager and told her that either she could shut up about the mixup in rent checks or talk to my (non-existent) lawyer, but either way, we wouldn’t be talking to each other again in this lifetime) and causes the bean counters and suits to prostrate themselves whenever one of my claims comes in, and cut their own throats rather than stamp one “Disallowed!”. I rather doubt it, though.
My husbands employer specifically bought the Blue Cross/Blue Shield plan we have because of my pre-existing condition (had a spinal fusion, have ongoing problems). He had to pay more for it, but let me tell you- I don’t pay for shit. (Except my usual co-pay). There is no calling ahead, no physician referals, nothing. When I needed an MRI, my doctor ordered it and I had it done 20 minutes later, I kid you not. Not a peep out of them. I do regular physical therapy, doctor visits, adjustments, etc and they just keep paying with no hassle.
The only thing I don’t like is that they don’t cover much for mental health care, which sucks. Oh well. The day he changes to an H.M.O is the day my husband changes jobs. I use health services too often to fuck around with that non-sense.
Sorry to hear of your problems, Eve. Don’t cancel your appointment, though. Take a deep breath, and keep calling ‘till it gets worked out. (I’ve been there, done that, glad I’m not still doin’ it)
Having spent several years in the field of healthcare reimbursement, and having worked for an insurance company and several radiologists (and I’ll address your problem in a bit, Eve), I am never failed to be amazed by some of the pinheads who also work in this field. I’ve had to follow up on claims that were denied because some jerk at the insurance company transposed numbers, and the provider services rep says “so, what of it?”
Even though your insurance carrier may be Swift & Scrooge LLC, if you protect yourself and make sure that you and your doctor’s office follow procedures, and read the information that you get each year. Keep the explanation of benefits, and follow up if the claim is denied. NEVER take the insurance company rep’s word as a final answer. Take it as high as you need to to get your problems solved to your satisfaction.
Eve, you do need an order for any test that is done. This is law, not insurance-company paperwork. Getting the referral is your doctor’s responsibility (in the sense that it’s his office that generates it; NOT having one makes you responsible for 100% of the cost). Call your doctor’s office and arrange to have it ready for pickup or see if they’ll mail it. Or, if you’re prepared to pay out of pocket for these tests, you don’t need the referral at all. It does seem like a lot, but it really isn’t. Finally, see if there’s a hospital imaging department close to you that accepts your insurance. They’re usually pretty flexible as to scheduling.
And, BTW, exclusions for “pre-existing” conditions are no longer legal under Kennedy-Kassebaum. (I’ve had more than a few discussions about THAT, too)
You can also lobby your employer to go with a company that’s more reasonable, but I wouldn’t hold my breath.
I have an HMO and I am pretty happy with it. My only gripe is that they don’t have claim forms for the occasional screwed-up charge that needs reimbursing. As someone else said, I am convinced it’s solely to make it harder to submit, so only the truly dogged will seek out the office address, call to see what the accompanying letter needs to include, etc.
Pregnancy & childbirth coverage was excellent, even when things got weird and both Cranky Jr and I needed to stay in the hospital longer than usual. Well-child checkups are also very good. Granted, I haven’t had any serious health problems (which is the true test of an HMO).
My coworker uses a different HMO, and recently had her daughter’s surgery refused for coverage after the fact. They followed every procedure as required vis-a-vis referrals, etc. But someone didn’t file the right form at one point. Based on this technicality, despite procedures being followed to the letter otherwise, the HMO used it as a reason to refuse to pay. No matter that their doctors all averred the surgery was required. No matter that it was a mere snafu by a staff member somewhere. I think she finally won on appeal, but not without considerable effort. She promptly switched carriers, which is funny: she finally got her daugher healthy, and now someone else will benefit from her premiums and normal use of medical care. The cheapskates are stuck with the expensive stuff: the specialists, the surgery, etc.
Zette, if I could take a deep breath, I wouldn’t need the X ray! I am just going to put the whole thing off till spring, when I usually have my mammogram anyway. The doctor said it’s “probably” nothing and prescribed some anti-cough stuff . . . No codeine, though, dammit.
My current carrier is Aetna/US Healthcare, and my doctor told me, “a lot of doctors are dropping that, as they are notorious for not paying.” I used to have Blue Cross/Shield, they’re the ones I had to sue (successfully, I may add!) because they refused to pay up when I had that spinal injury about 14 years ago.
Bastards, all of 'em, they should die like pigs in hell.
Aetna/USHealthcare is a billing specialist’s worst nightmare. They have so many hoops to jump through as it is, and every claim is a fight. I’ve heard of employers dropping them because they make life miserable across the board. They know their service is shitty, they don’t care, and they let you know they don’t care.
BTW, the one insurance company that ever gave me any problems on a personal level was BlueCross BlueShield Federal Employee, which took about six weeks to get me into their system. It was taken care of after I demanded to speak to a supervisor (not a customer service rep, or a senior CSR). The supervisor was very nice about the whole thing, and I was added to their system within a few days and had a card in the mail a day or so after that.
Ye gads. Aetna was the WORST HMO I’ve ever been on with my family. (At last count, we’ve been in…5 different ones.)
A close second was MAMSI/MDIPA. This was the one where every prescription led to a fight on the phone. The one where I had billing companies calling me because they never paid for my medical tests. The one where we had a fight every six months for my eye exams. Bleh.
Luckily, I’m in a PPO run through Blue Cross/Blue Shield now. It’s the best one I’ve ever been on…can go to ANY doctor I want, don’t need referrals, don’t need a primary care doctor…I love it. Woo!!
Great. All my doctors will probably drop Aetna and I’ll be stuck having to steal from drugstores and give myself surgery at home with kitchen implemewnts.
I don’t hate my health plan provider either. I have Aetna/US Healthcare and the one time I needed a sonogram it was no problem. I went to the Dr., paid my $2 copay, and was told to make an appointment for the sonogram. I made the appointment, called the doctor and told her when the appointment was, she put through the referral, called me back and said everything was fine. I got the test done, didn’t have to pay a dime, and the doctor called me when she got the test results and said everything was fine. It was just a cyst, and it eventually went away.
Didn’t really have any problems, except the doctor used my expired coverage at first. (I had Aetna previosly, and instead of using the number on my card, she looked me up by name and got the wrong account number)
The whole process of getting the referral, etc. was explained to me by the Doctor. I had no problem with it.
I had Aetna about 10 years ago. My dad & brother convinced me that it was going to be soooooo much cheaper in the long run. NOT. Fuckers. I had some goofy-ass $500 deductible, that did not include the cost of my prescriptions, which that the time were over $100 a month (I was on an expensive anti-convulsant at the time). The scrips? I had to pay those out-of-pocket, then submit the receipt for reimbursement. Money that I just did not have.
I had HealthPlus prior to that, and I switched when I got married the first time, because my premiums were going to jump from $7 a week for single-person coverage to $35 a week for married-no-kids coverage. That honked me off. After a year on Aetna, though, that $35 a week was lookin’ sweet. I never had a lick of trouble with HealthPlus. I left that job before I could switch, though.
My job now offers HealthPlus, and I signed up as soon as possible. To this day, I’ve not had a problem, and it’s been six years. $10 copay for office visits, $5 for prescriptions. Never had to pay a dime when my kids were born. And they’ve recently changed their well-woman care policies to allow the woman to more or less get what she needs, when she needs it, no hassles. I’m happy with it.
Where I work, you are given a choice between some HMO and a Cigna PPO. Most people chose the HMO, because it’s something like $5 a month cheaper. Fools.
Almost every doctor in my area is on the list of people I can go to. I don’t have a certain doctor I have to see before I go to a specialist, and if I want to go to someone NOT on the list, they will still pay the majority of the bill, just not all of it. I pay $10 for doctors visits and $10 for prescriptions. Considering how much it has been used lately, it has been worth it. If I ever worked for someplace that only offered an HMO, I would seriously consider shopping on my own for ‘real’ medical insurance.