Welcome To My Nightmare

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TucsonBill
TucsonBill Member Posts: 12
edited December 2017 in Just Diagnosed

I requested help here a couple weeks ago after my wife was diagnosed with breast cancer. Thanks to those of you who replied. Now I'd like to share a bit back with the community regarding what we have been going through and the bullets we've had to dodge and are still dodging.

(As I mentioned before my wife's English is not perfect and she needs my help which is why I post here on her behalf.)

First I want you to know that I was an insurance agent for MetLife for over 30 years. I took early retirement in 2015 and then worked for United Health Care from 2015 to 2017 in their call center for their AARP Medicare Advantage Plans and Medicare Supplement plans. I know a good deal about insurance and I must say I am shocked at how United Health Care tries to take advantage of at least "some" breast cancer victims, including my wife.

UHC has tried on at least 3 occasions to reach out to my wife regarding her cancer treatment. She has explained to them each time her language limitations and asked them each and every time if they could please speak to me instead. You would not believe the runaround we are getting.

UHC first had her believing that they would waive our $6,000 deductible if she would have her surgery at one of their "Centers for Excellence" which would mean ditching the surgeon we have lined up and also having to drive from Tucson,AZ to Phoenix for her surgery. The truth of the matter is they only waive the deductible as it relates to the surgery itself, not for all the other things like the ultrasound testing, MRI's, radiation, chemotheraopy, or the breast reconstruction. In other words, if the entire bill comes to $50,000, only a small portion of that is for the surgery itself there is absolutely no benefit what so ever in using their "centers for excellence" since the deductible and max out of pocket expenses still apply to all the other expenses. It makes me wonder how many women who's English is poor are being taken advantage of with this scam.

The second problem is that we have been trying for over a week to talk to our "nurse coordinator" that UHC has so graciously provided. When I call I am told they cannot speak to me because I need my wife's authorization. My wife calls to give her authorization and they say its a form she has to sign that they are mailing to her. First off, this is nonsense. As a licensed agent for UHC I could take 2nd party authorizations over the telephone on the recorded line when I was representing Medicare Advantage and Supplement Plans - UHC refuses to do this for my wife. We called back on a conference call to see if they could email or fax the form. The representative we spoke to said that only the appointed "nurse coordinator" for our plan could do that and that she would not be available until next Monday at 11:00. We had to set an appointment for a phone call to her as if she were a doctor. My wife's surgery is schedule for Tuesday morning. I have no idea what kind of coordinating she can do with less than a day.

To make a long story short, all United Health Care has done is make our life more of a nightmare by trying to continually mislead my wife and refusing to provide services.

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  • Beatmon
    Beatmon Member Posts: 1,562
    edited December 2017

    I'm so sorry that you have to put up with this VS along with everything else.

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  • Michelle_in_cornland
    Michelle_in_cornland Member Posts: 1,689
    edited December 2017

    Hey, Bill, I just got back to your other thread and saw your post to me. The income threshold for a family of 4 on the Health Insurance Marketplace is $98,000. Anything under that amount and a subsidy is issued. I studied Pharmacy at the U of A, and lived in Maricopa dorm....yes, with the sleeping porch.

    I am glad that your wife's surgery is next week. Her insurance does not sound like any bargain. BCBS does a great job here in Illinois in covering its patients. As with all insurance, you have to audit every bill, matching the insurance record to the provider record. I have found thousands of dollars of issues in one calendar year. If I continue to argue the bill with the provider, in the case of a bill that was renegotiated to my detriment with the insurance company, I generally win. I just keep calling every month complaining about what was initially said, written, submitted, etc.

    The latest crazy issue was a hospital, that is an in network provider to BCBS, had emergency room providers that were not in my network. My daughter had an incident at a sand volleyball court and needed her shoulder checked. I am fighting for clarity when using a hospital system in network, for them to make sure that their subcontracted staff are providers, in network, under my insurance plan. I am prepared to go to the Attorney General and Department of Insurance in my state, because this seems illegal an unethical to me. BCBS told me to take it to those state level organizations, but I am working through the CEO's office at the hospital to see what they can do first.

    Do you have any idea of stage or grade of your wife's biopsy?

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  • TucsonBill
    TucsonBill Member Posts: 12
    edited December 2017

    I was talking about AHCCCS in Arizona:

    "You and your family can usually get AHCCCS (AHCCCS) if your family's income is at or below 138% of the Federal Poverty Level (FPL) ($16,643 for an individual in 2017, $33,948 for a family of four). Children 18 years old or young can get AHCCCS KidsCarecoverage if their family's income is 205% of FPG or less ($50,430 per year or less for a family of four)."

    We are a family of three and the limit was about 40,000 when we last checked.

    Getting insurance through the marketplace the best we could have done was a bronze plan which was over $500 a month even with the subsidy and we'd still have had ~$7,000 or so max out of pocket exclusive of the premium.

    Even the so-called "free mammogram" under the ACA is scam. Its only free if they don't find anything wrong. If they find something its considered "diagnostic" and they turn around and charge you for it. Its all a racket.

    Good luck complaining to anyone. Because my wife's plan is through her employer the department of insurance in Arizona had no jurisdiction, it was also a big company that is self-insured, (Walmart), and the only regulation comes from the Department of Labor. The department of labor doesn't even have the authority to enforce the directives that it issues.

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  • TucsonBill
    TucsonBill Member Posts: 12
    edited December 2017

    OK I got a clarification from the Department of Labor, if the insurance company fails to abide by DOL regulations, then I can go get an attorney and sue them. Whoo-Whoo!

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  • Michelle_in_cornland
    Michelle_in_cornland Member Posts: 1,689
    edited December 2017

    Just got my provider with in a provider issue solved today by the CEO's office at hospital. They were just as perpexed as I was, why an ER contract employee would not have been in my insurance provider list. The list had not been updated. Problem solved, and money kept in pocket.

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  • TucsonBill
    TucsonBill Member Posts: 12
    edited December 2017

    Update:

    I got a computer call on Saturday from UHC confirming that our assigned nurse coordinator would call us Monday, (today), between 11am and noon. Both I and my wife made special arrangements at work to be available during that hour, (Originally I was told that the "appointment" was for 11am). When at 11:30 we had not received a call, we called UHC and were transferred to a special cancer unit. The nurse there took my wife's information, confirmed that it was OK to talk to me, (we were on a conference call), and then put us on hold to try to figure out who it was that we were supposed to receive the call from. She came back on the line and says that she sees in the call log that the appointment was set for 11:00 today but could not tell which nurse the appointment was with. I asked her if it was in the system now that it was OK to talk to me instead of my wife and she said that they still needed the signed form which was mailed to us which we have still not received. The nurse we talked to could not tell us why we needed to speak to a "coordinator" nor could she email us the form.

    UHC is absolutely pathetic. We never did get to speak to our nurse, the call never came and my wife's surgery is for tomorrow.

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  • Outfield
    Outfield Member Posts: 1,109
    edited December 2017

    Bill,

    I'm in healthcare too, although from the provider end. Some thoughts: why do you even need to talk to this "coordinator"? I have United, and every time I have an expensive scan they call me to "help" with getting it scheduled, which actually means that they suggest a place that's a 4 hour drive away in a podunk city where there is no really top-tier medical care. To their credit, they've covered all my scans done locally, but the pestering calls get annoying. My personal experience is that it's better to make sure my provider works with the insurance, then ignore offers from the insurance to "help." My big issue is figuring out who is on United's "list," since they (United) never seem to have an current one available to me. What I do is to ask the business offices of the providers I'm considering if they are "preferred," etc. Many oncology practices have a "nurse navigator" to help with clinical things, and frankly I'd trust someone in clinical practice far more than someone in an insurance company.

    Also, that's just wrong to change a "screening" to a "diagnostic" mammogram. Those are different tests, not just different labels. "Screening" is the standard few views they do for everybody once every year or two. In some ways, if you've seen one, you've seen them all - the general shape of the image, which directions they're done from. For a "diagnostic," the radiologist knows where the area of concern is and the imaging can be more tailored. It's definitely possible they could be done on the same day, in which case I imagine the code for the diagnostic would nullify the "free" part. The shitty thing is, cancer is expensive. People go bankrupt all time from medical calamities. Check out an itemized list from a hospitalization sometime - it's outrageous. Then go drive by an insurance executive's house and think to yourself, "They bought this with our money."

    And how morons use HIPPA - I often want to roar about that. I had a hell of a time getting in touch with my father's primary care doctor (he has dementia) when my mom was hospitalized, and could get no questions answered until the MD herself found out I'd been trying to ask them and called me directly. It way too often goes beyond common sense. Do they really think your wife is setting a trap and going to sue them if they talk to you? Does your state have a commission or agency that governs insurance? Also, could your wife have these conversations if they were in her native language? It would be interesting to know if insurance companies are obligated to provide translation, like medical providers are. Probably not, grrr.


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  • pingpong1953
    pingpong1953 Member Posts: 362
    edited December 2017

    I'm sure these insurance companies are very efficient when it's time to cash your premium cheques.

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