Sunday, March 22, 2009

Calm Waters Tonight

Finally My Head is Shrinking

The Headache is here but it is more distant and smooth, like evening ripples on a summer pond. I hurt elsewhere but The Headache is behaving tonight.

My headache diary was touchy to transmit again tonight - took three trys to get the silly thing to answer the siren call of the telephone. I almost forgot to even fill it out - I must make it a ritual to do at a certain time of day or I will forget and be non-compliant. I must be compliant in order to qualify. I do hope I have enough "headache days" to qualify. Not quite sure what the study sponsors consider a "headache day".... all of my days are headache days!

Tomorrow I will need to tackle Anthem again. I did a successful appeal of some ambulance bills from last year, and Anthem was to readjudicate these NOT using the "usual and customary" rate. The ambulance service which is non-participating with Anthem refused to accept the contractual write-off from these bills.

This is how modern medical billing works: If I had NO insurance, the ambulance service would automatically write off 20% of the bill. If I had their hospital system's insurance they sell, or another participating insurance they would have accepted the portion the insurance paid and written off the rest to contractual allowance. Since I have Anthem (with whom this hospital system has a long standing fight [pissing match] with) I was told I was responsible for 100% of the ambulance bill - worse than if I had no insurance at all! Their billers actually told me they didn't even want the partial payment, that I had to appeal. I won the appeal, and supposedly this was re-adjudicated but got paperwork from the ambulance service: apparently it is not resolved.

Anthem called me last Wednesday about the PET scan pre-certification problem. A lady named Coleen called just to make sure I knew I could appeal the pre-certification denial. I told her that I knew this, and complained again about their swellheaded contract physician who tried to advise my doctors on my care. That physician's job was to deny (and upon rare occassion approve) peer-to-peer review of service denial issues based on medical policy. He or she stepped beyond the bounds when he/she started dispensing opinions concerning my care.

Coleen wanted to make sure I understood they had a medical policy concerning PET scans. I am sure by their medical policy very few persons qualify for PET scans. I reminded her that policies are just that - guidelines to follow (generally to save the insurance company money) and that there are circumstances where policy is meant to bend, and by no means was I pleased that a physician who had never seen me, who obviously had not reviewed my medical record, and was not familiar with my case at all, was trying to dictate treatment instead of just administering a policy. Competency thy name is NOT Anthem. I am sure they have messed this up, or Coleen would not have called. I doubt it is standard procedure to call a subscriber especially to urge them to appeal a decision just made the prior day.

My personal opinion is that when the Blue Cross Blue Shields (WellPoint and Anthem aren't the only ones) starting going public and for profit their focus shifted from providing the best coverage at a reasonable cost to quarterly returns and stock price (which of course is what upper management likes to measure because they have a direct influence on their own stock options and bonuses). Too much managment focus on nest feathering and too little concern for their employees, quality, and their subscribers have changed the perception of excellence the Blues once stood for.

Ah well, this is why I am obviously not cut out for higher eschelons of management. I have no patience for greed, and most corporations seem to assume that managers will operate out of self interest instead of the good of all. The incentives and initiatives I observed when I was management all were geared to appeal to shortsightedness and personal gain. This current financial mess the world is in is because of this sort of business philosophy and everyone having his/her hand in someone else's backpocket.

I guess I'm done being gripey tonight. Tomorrow is another day! Hey, at least I'm not just droning on about how my head hurts tonight!

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