
The other night, about a half-hour before President Obama gave his speech to a joint session of Congress, I got a piece of mail I'd been expecting. It was not, as I hoped, a check for 80 percent of combined allowable charges by the clinical psychologist and psychiatrist I'd recently begun seeing. Instead, it was a four-page claims reply that concluded with the following:
Under this member's coverage, benefits are not available for this type of service when rendered by this type of provider. Therefore, we are unable to provide benefits for these charges. Please refer to your employee benefit booklet or contract for additional information.
A little background: I have had recurring bouts of depression since I was 12. For those of you who don't know, that's not walking around in soft focus to the menacing strains of a bass viola while concerned family members look on. (A more accurate ad would probably feature someone fantasizing she is hanging herself or spending the household savings on transistor radios in a manic episode, but might be a little jarring when the happy pill appeared and the music went into major.)
I also have insurance. It's actually very good insurance, a PPO, BlueChoice of Maryland. Because it's a PPO and not an HMO, I can see any provider and receive 80 percent of allowable for my $300-a-month premium. Between gynecological exams, lab tests, infected retinas and monthly doses of Klonopin and Lamictal, I have probably only spent about $1,500 out of pocket in the past year. When I was employed full time and not on COBRA, my old boss even paid the deductible.
But many mental health professionals don't accept insurance company negotiated rates. In my adult life, I have probably spent about $70,000 out of pocket for my care, not counting premiums. Many insurance plans offer in-network psychiatrists and psychotherapists at a more reasonable rate through an outsourcer, such as Magellan. A couple of times, I used their doctors in crisis. The first talked about how I went to Yale and he went to Yale; the second burst into tears and left the room within the first three months of our work together. Finding a mental health professional is not as easy as finding a gynecologist -- oh wait, that's not easy either.
I was optimistic this time because I know my PPO does pay for mental health care. I once went to a clinic attached to a hospital affiliated with BlueChoice and they approved me for 12 sessions quarterly, with no denial of coverage.
But apparently that was because my old doctors had a deal with BlueChoice, and apparently my current medical providers don't. So much for paying 80 percent for whomever I see. Unfortunately, I've already laid out the money and now learn my insurance company doesn't have to reimburse me.
The other night I caught a repeat of a Bill Maher show in which Joe Queenan asked why people who already have insurance should decide to help those without. "I like my insurance!" he said. "You probably like your insurance, too. So tell me why should I have to pay for other people who don't have insurance, other than being selfless?"
I submit that the statement, "People like their insurance" is not true. What Joe means to say is those who only use their insurance to cover treatment that fits within the profit model of the insurer like their insurance. People like me, whose illnesses fall within a hazy DMZ of coverage-worthiness receive explanations of [no] benefits that tell us, "See remark M829," hate our insurance. Even a reputable insurer will make the process so Byzantine, so laden with refusals and obfuscations, that to get them to honor the contract at all, a patient must present bundles of documentation.
A few years ago, my insurance company, MegaLife, denied my claims for the anti-depressant drug I was taking, Effexor. First it said it didn't have to pay because it didn't cover that drug. Then it said the drug was actually psychiatry, and it didn't cover psychiatry. Then it said it only had to pay 50 percent because it did cover psychiatry, just at 50 percent. (I always pictured a dumpy little person running down the hall to a supervisor and saying, "Okay, what do I say now?") I finally got reimbursed after filing another appeal with the Maryland Insurance Administration, and sending copies to every person on the letterhead, including Gov. Martin O'Malley.
My entire medical care rested on how scared I could make some functionary in some office in Phoenix, Ariz.
And now I have to begin the process again. I will call BlueChoice, which will involve being sent from department to department, knowing no one will know anything or think I am at the right department. I have to look through my records and find proof of BlueChoice covering care like this for me before. I have to draft another appeal to both the Maryland Insurance Administration and BlueChoice, knowing that they will probably deny the claim and then once I re-file will tell me the 60 days are up. I will have my doctor write a letter. I may have to go to a hearing or wait six months, hoping BlueChoice either decides I am not worth this effort or becomes scared that a judge at the end of my state appeals will think I am.
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