September 09, 2009
My colonoscopy saga-2: When 'routine' does not mean what you think it means
In my first post in this four-part series, I pointed out that the choice of doctors and hospitals is very limited in the US. But as I continue to look further into my 'free' colonoscopy I discover more pitfalls.
I know that insurance companies try to find ways to avoid paying so I analyze my policy carefully and call the insurance company and ask what the word 'routine' means, since only those kinds of colonoscopies are free. I am told that the colonoscopy is considered routine if it is done as part of a regular check-up and not because of any symptoms that might suggest that I may actually have colon cancer.
This strikes me as bizarre, that the procedure is free only if there are no indications at all that I have any problem. The slightest hint of a symptom and bang, I am on the hook for well over a thousand dollars, the cost of the procedure.
This is of course consistent with the profit-seeking model of the private health insurance industry in the US, which seeks to only insure healthy people so as not to pay for treatment. Think for a moment of the consequences of such a policy. It means that people who suspect that they may have colon cancer but cannot afford to pay for the exam may not seek early diagnosis and treatment (and early treatment is key to a successful cure for colon cancer) but instead gamble that there is nothing there. It also means that if the insurance company can find anything at all in my past history that could be considered an indicator of colon cancer, they can deny payment. In fact they have huge staffs whose sole task is to try and find such 'pre-existing conditions'.
But in my case, I had no symptoms so I called my primary care physician to get a referral to a gastro-intestinal specialist who does colonoscopies. He gave me a few names of people he thought were on my plan and thus should be covered. Of course, I have learned never to trust this kind of hearsay information because my primary care physician has to deal with dozens of insurance company plans and the bureaucratic maze that is the insurance industry, so I go to the insurance company website to check for myself.
The website is a nightmare to navigate. You have to select from a bewildering menu of insurance policies and within them, subclasses of policies. As Uwe Reinhart, a professor of political economy at Princeton University, said, insurance companies offer a range of policies under various names and in the employer-based health insurance system that exists in the US, each company negotiates its own benefits package. So you have to find the specific plan offered by the specific policy you signed up for from those offered by your specific company. But I am determined and plow on, having to call the insurance company a couple of times to clarify that I was on the right track.
And success! One of the recommended doctors is on the approved list. I also found that the office he works in is on the approved list of facilities. So I call the doctor's office and speak to a receptionist there to make an appointment. Of course the first thing she asked from me was my insurance information because nothing gets done in the US unless you can prove you can pay, not on how sick you are, which is another bizarre aspect of US health care that people have become persuaded is 'normal'. Once my ability to pay was settled, she said that before they could schedule the actual colonoscopy, I first needed an office visit to meet with the doctor for him to evaluate me.
This seemed perfectly reasonable, but it set off an alarm bell in my wary head. Was the office visit also covered by my insurance? I called the insurance company again just to be sure everything was ok. They said that the office visit was not covered. I argued with them that if the doctor required an office visit as part of the colonoscopy procedure, then it should be considered part of the cost of the colonoscopy and should be covered. After some back and forth, the person I spoke to put me on to her supervisor who, after some more back and forth, finally said that if the colonoscopy was done within 2-3 days of the office visit, it would be considered part of the colonoscopy. Otherwise it would count as a regular office visit and I would be charged in full for it.
This seemed absurd to me. She seemed to be making this rule up (the vagueness of the '2-3 days' seemed suspicious). So I called the doctor's office again. They had never heard of this 2-3 day rule. They transferred me to their billing office. The billing office manager was also baffled by this rule and she called the insurance company to find out what was going on. Of course, the billing office manager got a different insurance company person from the one I spoke to, and the new person said that she has never heard of this 2-3 day rule either and that the office visit is fully covered as part of the colonoscopy, irrespective of how many days separate the two.
The doctor's billing office calls me back with this information. I am still a bit suspicious and call the doctor's office to see if the office visit can be scheduled within 2-3 days of the colonoscopy, just in case. The answer is no. Why? Because the office visits takes place in one facility on one set of days and the actual colonoscopies are done in another facility on another set of days. But the fact that I have just learned that the colonoscopy is done at a different location from my doctor's office sets off another alarm bell. Is that also an approved facility in my highly restricted list of choices? Once before I had experience of having some tests done at a non-approved facility that was used by my (approved) doctor and having to pay the full cost, so I am a little suspicious. I go back to the nightmare of the insurance company website and after much searching and another call to the insurance company, I find that it is, which is a relief.
So, am I all set for my 'free' colonoscopy? Don't be silly. You think the insurance companies give up that easily?
Next: More problems with the word 'routine'.
POST SCRIPT: The US has the best health care system in the world?
Opponents of health care reform like to boast that the US has the best system in the world. What such statements tell me is that these people have no idea what people in other countries have.
In yesterday's Fresh Air, Terry Gross had a poignant interview with two young women who were diagnosed with cancer while still in their twenties. Like many young people, they were either uninsured or underinsured.
One of them was originally from the Czech Republic and she found it cheaper and less of a hassle to regularly fly back to that country for the free and bureaucracy-less treatment she received from the socialized health system in that country than deal with the system here. Think about that for a minute. The doctor who had initially diagnosed her and whom she trusted had since been removed from her plan which meant that she had to pay a huge amount just to see the doctor of her choice, which also makes a mockery of the claims that patients have choices in the current system.
The other woman was fortunate enough to marry a man who had health insurance coverage under his employer-based group plan that did not deny people with pre-existing conditions. So she is now covered though she still has to deal with the hassles that are routine here.
Both of them spoke about the nightmare of having to deal with the hassles and bills and the bureaucracy of the US health insurance system while they were still reeling from being told that they had cancer.
And these are the lucky ones who had at least some options. They are surviving. But for every young woman like this, there are many who have no options other than to go bankrupt or die young or, as is more likely, first go bankrupt and then die young.
As they say, only in America.