[cancer] The magical land of health insurance

So let me start off by saying that my health insurance carrier has actually been quite supportive through the cancer experience thus far. Until the last few days, I’ve experience zero chain yanking and a great deal of positive, useful support from them, largely in the person of my cancer case manager.

However, last week I got a coverage letter telling me my oncologist is out of network for my PPO plan. This triggers an entirely separate deductible process, wherein I have to pay the first $2,500 for out of network coverage, after which I then pay 30% of charges instead of my usual flat co-pay. That would mean another $2-3,000 out of my pocket this fall, given where everything is going.

Finally got through to my case manager yesterday to discuss this. She verified they had no listing for my oncologist, and strongly advised me to find another oncologist. Long discussion about networks and coverage. My case manager was being as helpful as she could be within insurance company rules, but from my point of view, this whole thing is madness. They’re already preparing to spend about $250,000 treating me, and they’re barfing on $2,500 or so worth of doctor bills. Starting with the $279 sitting on my desk right now.

I called the clinic at my primary hospital after I got off the phone with my case manager, to explore it from their end. For example, could they rebill, etc. The medical administrator there was quite surprised to hear that my oncologist was out of network. According to her, all the doctors at the clinic are in network with my carrier under a master contract. Long discussion about networks and coverage. Much frustration on my part.

This gal is a Hero of the Revolution, so far as I am concerned, because she took my information and promised to call the health insurance company from the provider side and work through this. Still, what a mess.

Health insurance reform isn’t just about access, it’s about sanity. Or at least it better damned well be. With the exception of almost being killed by ER triage last year (literally), my experiences with the healthcare delivery system have ranged from good to admirable. My experiences with the healthcare finance system have ranged from adequate to surreal.

Also, in discussions with the case manager, we began reviewing the collateral medications associated with chemotherapy. I’m going to be a walking pharmacy before this is all over with. Anti-nausea, anti-inflammatory, anti-anxiety, et cetera, et cetera, ad nauseum. My biggest concern about the chemo trip is preserving mental acuity, so I’m very dubious about steroidal anti-nausea drugs, as well as anything psychoactive such as anti-anxiety drugs.

Upcoming I have another CT scan on 7/20. That’s when we discover whether or not my lungs are a pair of tumor sacks. We’ll also validate some of the other data and assumptions about liver and lymph. Unless something unexpected arises from that scan (or unless I have to switch oncologists for insurance reasons), I’ll have my chemo prescribing appointment on 7/27. With luck, I can get the Harkonnen heart plug installed quickly enough to go to Worldcon while I’m recovering from that surgery, and begin the chemo when I get back.

I’ve decided to leave further documentation of my emotional freakouts for another day. Plenty of more-or-less objective detail here now. More as it develops.

6 thoughts on “[cancer] The magical land of health insurance

  1. Been there, done that. Several times with several carriers. When I broke my leg I required three surgeries (one to put the hardware in, one to remove the osmotic screw, the final one to take all the hardware out), and two trips to the emergency room. I had to fill out the same form five times. That form basically boiled down to “Can this be covered or can we sue someone else’s insurance.” All for the same condition. For the one surgery we also had the insurance make this claim (they’re not in the network) for the anesthesiologist, although we had to clear that one up from the insurance side (and yes, they were in network).

  2. Jonathan says:

    Amen to sanity. I can’t say I’ve ever dealt with health care on the same scale as you, but I imagine anyone with insurance has had a glimpse into that wacky world. “Insurance” is anything but. Insurance is supposed to make us feel secure, but instead it compounds our anxiety. It’s bad enough to be in a condition that causes us to enter the strange world of US health care. The dread increases with the anticipation of wrangling with insurance companies. I’m glad you have an advocate in the system and I wish you well.

  3. “Health insurance reform isn’t just about access, it’s about sanity.”

    Until someone has been through something terrible like this, they just can’t understand how true your statement really is… With my son’s cancer, we went round and round with the insurance company on just how many MRIs he could have. Thankfully, we have a great Children’s Hospital and they took care of most of it, but it’s so frustrating to deal with healing AND bureaucracy at the same time.

    Hang in there, Jay.

  4. Joy says:

    ach, Jay… The deeper I dig into the health insurance nightmare, the crazier I get – and since what brings me to health insurance in the first place is mental health treatment, you can imagine this isn’t a positive outcome.

    I flat out had one provider tell me that the top folks in the field had begun to leave the rolls of the insurance providers because they were tired of arguing for treatments and procedures that were being automatically denied on round 1 and similar ‘cost saving’ tactics… It is utter craziness. When I was trying to get my gastric bypass surgery past the clerks at Aetna in 1998 I finally threatened to come in and cut my wrists on their desk to prove it was having a detrimental effect on my mental health; I never did get a phone call back but I did get an approval notice for the surgery. I guess I want to say both hang in there and don’t be afraid to make bold strokes in defense of yourself – when the system becomes Gilliam-esquely Brazilian it really does call for that level of response, sometimes.

    1. Jay says:

      Thank you, Joy. Slowly it unfolds…

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