Things I don’t like: health insurance

Last month I wrote my first Things I don’t like post. It’s time for a follow up, and this time I’m going to pick on insurance companies, specifically, health insurance: both medical and dental.

Reading a Grumpy Rumblings post this morning that pointed to a New York Times Opinion article reminded me of my gripe. This NYT article is excellent and really must be read. Go ahead, do that now and then come back here.

The points of the article that really resonate with me are that it can be very hard to purchase insurance in the open market, and that without insurance medical necessities such as tests and medications cost so much more. What a truly screwed up system we have! It charges people paying cash up front more than people who require the medical provider to bill an insurance company. Doesn’t the medical provider then have to wait to get their money? And they have to pay for people to do the billing and monitor the status of the billing, too? Aren’t these more expensive to the medical provider? I just don’t get it.

I have insurance available to me through my job. I do pay for some of it, but it is heavily subsidized by my employer. I also have a choice of medical plans, so I can pick one that fits my needs. I use a PPO plan (which stands for preferred provider…something or other) because it allows me more flexibility when choosing medical professionals for my care.

Last fall during open enrollment I actually considered not enrolling in the PPO plan this year and instead going with a high deductible plan. With my current PPO plan, I can also take advantage of the medical flexible spending plan (FSA) that allows me to withhold money pre-tax for expenses not covered by insurance, such as deductibles and co-payments. However, with a high deductible plan I could have started a health care spending account, which allows more pre-tax withholding of money that can be rolled over every year, unlike the medical FSA which must be used within a single tax year.

It wasn’t the tax sheltering that made me think of a high deductible account, though. It was the fact that I do so much medical care out of network anyway that I feel it may be a better value for me. Plus I knew this was going to be an expensive year and I thought it may be better to look at 2011 as the year I actually have enough medical expenses that I would qualify for a tax deduction. But only if I didn’t participate in the medical FSA.

The reason this was going to be an expensive year for me is that I am getting a lot of dental work done. And here’s where the extreme dislike comes in: my dental insurance is screwing me over. It’s nothing personal, I know. This is just their standard operating procedure. One of the ways insurance companies scrape out profits is by delaying payment by denying claims. The claimant must then contest the denial, and the insurance company has extra time to “examine” the merits of the claim. This is exactly what is happening to me and I hate it.

This all started last fall for me. I finally decided to give in to my dentist’s recommendation that I visit an orthodontist about getting my bottom teeth fixed. They’re crowded and overlapping which makes cleaning and maintenance a real challenge, and since I want to keep my teeth for as long as possible it was time to address the problem. So I saw an orthodontist and he recommended I consult with a periodontist before starting any orthodontia because there was a bit of gum loss in some areas. I consulted the periodontist last year, too, and scheduled my first procedure with her for January since I had already tapped out the medical FSA for 2010.

In mid-January I had a gum graft done. It was an intense experience for me since I had never had a dental procedure that required Novocaine or consciously laying there while someone performed delicate surgery in my mouth. (I did have my wisdom teeth removed when I was 19, but it was done under general anesthetic so I was completely unconscious.) After it was over, I got even more shocking news: I would have stitches in my mouth for about six weeks and I needed to pay the the full $3,000 bill right then and there and wait for my dental insurance company to reimburse me later. Gulp. Thank goodness they took Discovercard.

The periodontist submitted the claim for me the same day and a week later I got the Explanation of Benefits (EOB): denied. The insurance company needed more information to process the claim, and the code on the EOB pointed to something about…x-rays?! I called the insurance company and asked for clarification. Yes, they said, they needed x-rays. I told the agent I was confused. Did they not understand I had a periodontal procedure that involved simply soft tissue work? How could they assess the need for soft tissue work from an x-ray, which only shows bone? She insisted they needed x-rays and that was that.

I happened to be seeing the periodontist that day for a check up, so I talked to her about this issue. She said she would file a complaint form showing that her professional association did not recommend x-rays for soft tissue work like gum grafts. For anyone with a modicum of understanding of human anatomy, this makes sense. And for someone like me who is being treated for hypothyroidism, getting irradiated unnecessarily in the head and neck area is really not a good idea.

The periodontist also commented that this is not an unexpected outcome when dealing with insurance companies. They typically deny claims once or even twice before finally paying. Each time they have 30 days to evaluate the contested claim. That means that a person like me has to front the big insurance company thousands of dollars for up to two months. Until I get the final EOB I can’t file for reimbursement through my medical FSA either. So I’m just out the money until I can get the insurance company to cough it up.

As I said to another agent of this insurance company during one of my follow up calls, it’s despicable how hard they are making me work for my money; money I’ve paid them diligently over many years. I’ve had dental insurance for nearly 13 years now and paid premiums to them every month. During that time I’ve only had the basic services done: biannual exams and cleaning. That’s it. The one time I make a claim, they screw me and make me jump through hoops.

There is another important lesson buried in here: emergency funds are essential for things like this. Yes, I charged the procedure to my Discovercard, but when the bill came due I didn’t want to ask Discover to finance my procedure. That would have made a bad deal for me even worse. So I transferred a bit from my emergency fund to cover the unplanned bill, and when I get reimbursed (some day) I will transfer the money back to the emergency fund.

Thank goodness for emergency funds! Thank goodness for planning ahead! And shame on Metlife Dental.

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5 thoughts on “Things I don’t like: health insurance

  1. Pingback: Things I don't like: health insurance « a windycitygal's Weblog | Insurance Blogs

  2. Pingback: Things I don't like: health insurance « a windycitygal's Weblog | Insurance Blogs

  3. I have often wondered if, in all this health insurance debate, someone has figured out the cost savings to insurance companies if they just process claims correctly the first time. I’d always figured it was just plain old incompetence!

    Like

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