Nowhere to Turn: The Misery of a Failed Health Care System
The first months after our son James' car accident in July 2012 were dreadful. He was involved in a head-on collision that required an hour to remove him from his vehicle using the “jaws of life.” His crushed face required extensive reconstruction, a spinal tap to relieve cranial pressure and weeks of one-on-one care in the surgical ICU. After he was discharged from the hospital, months of fretful family caregiving followed, with long stretches of paralytic inactivity in between (me on the couch and Rich, my husband, in the recliner). We were in that state of shock for such a long time that I thought we might never recover or that the "new normal" would be dark and fraught with peril at every turn. However, at some point, the jagged edges of our lives began to ease and we all seemed relatively well, except for one looming issue.
We found that we were facing the payment of a large chunk of James’ surgeon’s bill, made impossible to ignore by the $11,080 statement we received routinely every month in the mail. Why were we burdened with this? Because unbeknownst to us, the surgeon called to be a part of James’ trauma team that night was “out of network” and charged more than what was “allowable” under our insurance plan. Should this matter in an emergency? Should we have been required to find another, less costly and thus insurance-approved surgeon and risk an inferior outcome that could literally impact the rest of our son’s life?
During the initial months of my s/low functioning, I began repeated attempts on two fronts to either get the remaining fee paid by our insurer or forgiven by James' surgeon, which is typical in these situations. I was consistently repelled by both. My technical appeals and the “statute of limitations” expired with the insurer, because the process was stalled for a year, and we were left with a bill that the surgeon refused to write-off that will take us 9 and 1/2 years to pay. We will be close to retirement age by the time Dr. ABC gets his money. How did this happen? We had what we thought was good insurance (Blue Cross and Blue Shield of Louisiana), a supportive employer (The LSU System/LSU AgCenter) and a sympathetic physician? Here is my story.
Approaching the Insurer:
My first approach was to argue that the insurance company's reimbursement rate for the surgeon's bill was inadequate- literally, by about 1/3 of the amount he had charged. I had to force myself to fight with the insurer for our financial health, considering the weight of the worry I was carrying. Nevertheless, Blue Cross was my first target because, after all, this wonderfully skilled surgeon had rebuilt the left side of my son's face and likely saved his life. Anything he charged seemed to me like it should be paid. I had several frustrating phone conversations with Blue Cross and Blue Shield with me pointing out their "denial errors," – e.g., "the surgery was not dental surgery therefore it is covered by your policy,” etc. A lawyer friend suggested I call the Louisiana Insurance Commissioner and ask for help, which I did. The Commissioner's office was very responsive and empathetic but said that although they recommended our insurer pay the full fee, they could not help us, because they did not have jurisdiction over our case. Why? Because we did not have "health insurance."
What? No, insurance?
No. No, insurance.
Apparently, unbeknownst to us, the LSU System/AgCenter is self-insured. However, I told them, I remember we chose the Blue Cross and Blue Shield of Louisiana Plan (and Ochsner before that, and Humana before that- both of which were cancelled) from among many insurance plans presented to us during annual enrollment. Right? In addition, what about the Blue Cross Insurance Card I carried around and presented to doctors and hospitals when members of our family needed medical care?
Apparently, that card also had the name of the Office of Group Benefits on it, and that meant something (which is now explained on the back of the new cards issued to us- “Blue Cross and Blue Shield of Louisiana provides administrative services only and does not assume any financial risk for claims.” Was that there at the time of James’ accident? No.). What that meant was that BCBSLA was just a “third party administrator,” or more specifically, just the creator of the terms of the plan, and the claims processor. However, claims are actually paid by the LSU System's Office of Group Benefits.
It was at this point that I discovered that the entire LSU System is self-insured, but in order to find that out, I was told, "you have to ask questions."
Information explaining the meaning of a third party administrator, or that LSU is self-insured were not written on any of the materials we received from our "insurance plan," or any insurance plan offered by the LSU System that you choose, including in the contract containing the terms of the plan. It is not discussed by any of the representatives from the insurance companies that visit LSU to tell you about their company, and their "company's policies" (that you should be sure to sign up for).
At about the same time, I wrote a letter to Blue Cross and Blue Shield of Louisiana, which apparently constituted my first appeal, and their response was to send my letter to the LSU Office of Group Benefits, and to refer me to the terms of our "BCBSLA contract." The long and the short of that line of inquiry was that even though the contract stipulated that (elective) out of network physicians, like ours, were paid only 70% of their fee (with an out of pocket maximum per individual of $1,000), 70% of the fee was not paid in our case (nor was the $1,000 out of pocket minimum honored).
Apparently, another sentence in the contract says that payment will only be made according to the "BCBSLA allowable fee schedule," and our surgeon, Dr. ABC charged more than their “allowable fees.”
Where do you find the BCBSLA fee schedule? Well, it is not listed in the contract, or anywhere else I have been able to identify.
Approaching the Employer:
After appealing to the Office of Group Benefits for help and being turned away -after they had an executive meeting on the subject of our claim (after a long delay, because, “everyone quit”)- I did discover that the Office of Group Benefits had paid 100% of the "BCBS allowable charges," because James' accident was an "emergency." However, again, what they considered "the allowable fees" were approximately 2/3 less than what Dr. ABC charged, or $5,836. At about that same time, I learned that the terms of the BCBSLA contract stipulate a one-year statute of limitations. In the state of Louisiana, contracts for insurance have a statute of limitations of up to 10 years, unless otherwise stipulated. Ours was stipulated. I was running out of time.
Approaching the Physician:
We approached Dr. ABC a number of months after the accident, in a physician's visit with James, as he was unhappy with, and depressed about the way his eye looked, and the amount of discharge draining from it. Approaching Dr. ABC seemed like the next reasonable step, because soon after the initial surgery, Dr. ABC told Rich that he would wait at least six months to do additional surgeries on James, because his face had to heal; but not to worry, that he would get everything the way he wanted it, because "insurance would pay for everything and future surgeries would not be considered elective." By the time we got to that appointment, Dr. ABC had received my letter to Blue Cross and Blue Shield of Louisiana, so knew that we were at a stalemate with Blue Cross, payment-wise. He even complimented me on it. But, in the discussion that ensued, his attitude toward additional surgeries literally did a 180; he did not seem to remember that he had suggested James could or should have any additional work. In fact, he cautioned James against seeking perfection.
"You don't want to get into that trap," he said.
Rich did phone Dr. ABC and confront him about his change of attitude about additional surgeries, to which Dr. ABC replied that there must have been a miscommunication. What we learned from that visit and subsequent emails/phone conversations was that his office had opted out of being a preferred provider for Blue Cross due to numerous disagreements over payment amounts; and that Blue Cross, as a policy, literally, will not speak to out-of-network providers. To wit, we tried to have a three-way phone call-- Blue Cross, Dr. ABC's office and me- that was unsuccessful, to say the least.
Blue Cross would not participate.
When we again tried to speak to Dr. ABC directly, his office staff said that he was not involved in billing discussions. The message was clear-do not attempt to contact him again. I had hoped that both the insurer and the physician might help us resolve this issue- but, communications amongst the three of us proved to be an impossibility.
The onus for determining what is a fair charge/code/price/reimbursement was on the insured or the patient- individuals who know the least about the system or where to locate relevant information. The bottom line for insurance companies is that if you are a "preferred provider physician" you will write-off any remaining amount that is not paid by the insurer. Dr. ABC's office was not a preferred provider, but we practically begged him to forgive the remaining amount. The response? His billing office told us specifically and emphatically that they do not do that because they "would go broke." Mind you, a good portion of Dr. ABC's practice is elective, plastic surgery.
Research- What was this surgery worth?:
My next step was to go back to what I knew best- and that was research, and research methods. Were the codes submitted by Dr. ABC's office for payment "reasonable?" If they were reasonable, were Blue Cross's "acceptable reimbursement amounts" reasonable? The law stipulated that I could request James' medical records/the codes -they were provided to us by the hospital claims department, the physician's office, and the insurer. So, billing codes in hand, I looked up everything I could find on facial reconstruction CPT/ICD9 billing codes- what codes were used for which procedures, and how to code to get reimbursed the greatest amount, etc. I found the American Medical Association website and their recommended payment amounts for medical codes by state. What I found was that the amounts charged for Dr. ABC's procedures by Dr. ABC's office, under the codes he submitted ($17,900~), were both incorrect and in one case many times higher than what was recommended. I also discovered that "Blue Cross" or the "Office of Group Benefits" had paid more than two times ($3,800~) the amount for the main surgical code (21182) as was recommended by the AMA ($1,900~). When I talked to Dr. ABC's office staff about the AMA recommended reimbursement amounts- they pointed out the small print on the website, which said that amounts stated therein might vary by physician and region. When I asked which coding book they used-- they told me The Physician's Coding Guide—(which book recommended a payment amount for the 21182 code from $6,395 to $7,941)-- but I simply could not find it anywhere.
When we discussed their mistake on the main code- they quickly investigated it and determined that, yes, in fact it was incorrect, which they wanted to rectify with the insurer through an appeal, immediately, (which they said would reduce their charge on the main code to $7,900). At the same time, they finally looked at the other codes for other procedures that were on James' bill, and stated that the codes recorded were not those that they had submitted (inferring that someone else changed them). They wanted to change/correct those too, because of something about the insurer thinking that they "bundled" codes when they did not. Fixing this misunderstanding would increase the reimbursement amount (which they said would reduce our $11,080 bill by $1,500 or to $9,500).
This critical look at the billing codes by Dr. ABC's office happened, finally, almost a year after the accident. Despite our calls/emails/visits/complaints no one made a point to try to assist us. Their response over time was to refer us to their billing department and try to put us on a payment plan. A few months later, Dr. ABC's office received the denial of their appeal from The Office of Group Benefits/Blue Cross dated the very day that the Statute of Limitations had run on our claim, 7/11/2013.
At that point, they called and again tried to put us on payment plan. The futile and emotionally draining breakdown in the system had run its course. Under extreme duress, my response was that I would not pay, and asked them to refer our bill to a collection agency, as I had heard collection agencies would at least negotiate the fee amount. Rich’s later communications with Dr. ABC's office determined that they do not refer bills to a collection agency. They have their own.
Where are we now?:
As I said, we are now on a payment plan that will take us over 9 years to payoff. The payment booklet is hidden from me somewhere in the house. Without any other recourse, Rich agreed to their proposed plan and is paying on schedule and on time. I cannot be involved..
During the final phone call my husband had with Dr. ABC's offices, they said that if Blue Cross would have accepted their appeal we would have actually owed more (uh, they were the ones that coded that main code incorrectly, which is why all of the codes were resubmitted). I wrote them an email explaining that we wanted to know the amount Blue Cross would have paid if they had agreed to the code changes that would have corrected the bundled payment misunderstanding. I flatly said that the other coding mistake was their fault and should not be calculated in the amount we owed.
I did not expect a reply. I did not get one.*
Dr. ABC might be a great surgeon but there is something missing if he does not demand that his employees show compassion and assistance toward his patients. In the end, money trumped humanity. All three members/pillars of the system failed miserably.
--
*Well, I guess I did receive a reply from Dr. ABC's office:
Our most recent bill now says that the amount we owe is $10,180, rather than the $9,580 reduced amount, even though in 8/5 and 10/23 emails Dr. ABC's office said they would decrease the amount of their bill, and not increase the amount due to their error (which I pointed out). This pretty much exemplifies how we have been treated by James’ surgeon’s office. At some point I will call and question/argue with them about this. It will be in the new year-- the on-going effort and affront/assault by his office is exhausting. Merry Christmas.
