Health Insurance not very reassuring!

A couple of weeks ago, I had an exam because of some odd symptoms that seemed similar to what my mom went through, 4 years ago. Everything checked out ok, but my doctor ordered a follow-up ultrasound, just to make sure. I called my insurance company and they are telling me that I don't have 'reasonable concern' to have an ultrasound covered. I guess it doesn't really matter to them that my mom died from OVC, last summer. Not only that, the ultrasound wouldn't even count towards my deductible. It would be completely out-of-pocket.

My doctor will have to call them and figure it out. It is frustrating the way the system works. I tried to explain to them that it is in everyone's best interest to allow women to error on the side of caution and not wait until it is too late to do 'follow-up' ultrasounds. It should be common knowledge, especially with insurance companies and their close-knit relationship to hospitals and clinics, that too many women are misdiagnosed before getting treated for OVC. It is so uneccesary.

The irony in all of this is that what my mom did for a living, before retiring, was medical case management. She would give the yes or no on whether or not procedures could be covered, for a particular insurance company. She was an RN for several years and understood how all of this worked. I tried hard to fight back the tears, as I got no where with my insurance.

It made me sad to realize that this is the way it is. There is no compassion, despite how much a representative wants to 'be human' with you, their hands are tied by rules and more rules. I would imagine that their jobs are not easy, day in and day out.

My comfort lies in that God is in control. I am not fearful, but I am also not ingnorant. It is sometimes difficult to fight off fear when it comes. I allow myself to express the emotions I need to, and then I do the next thing: change another diaper, wipe up the floor(again!), or pay another bill. Life continues; and I want so much to live every day to the fullest. My babies need me here as long as possible.

I did not have the chance to grow up with my mom and have that mother-daughter bond, that I see so many other people have. We were separated for much of my childhood, due to some difficult circumstances. I now realize that in my initial grieving her loss, the ongoing grief I've had for my entire life is likely due to an attachment disorder or something like that(they have names for everything these days! ). I am pursuing therapy and look forward to meeting the right counselor for my situation.

Every day is a blessing, no matter how crappy it may be going : )

By gpawelski
Posted August 29, 2009 at 8:46 am
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Your mom's experience in medical case management is what we hear as "having a corporate bureaucrat between you and your doctor." Her knowledge could have been an invaluable on how the private insurance industry works.

Former Cigna Insurance Company executive Wendell Potter, after visiting an open air clinic for the uninsured and underinsured, has left his lucrative position in the industry to speak about the insides of the health care insurers. I hope you have remembered what your mother learned and will speak out about it too. I'm sure your mother's spirit will help you. This posting is but one example.

The industry is driven by two key figures: earnings per share and the medical-loss ratio, or medical-benefit ratio. That is the ratio between what the company actually pays out in claims and what it has left over to cover sales, marketing, underwriting and other administrative expenses and, of course, profits.

Think about that term for a moment: The industry literally has a term for how much money it "loses" paying for health care.

The best way to drive down "medical-loss," is to stop insuring unhealthy people. You won't, after all, have to spend very much of a healthy person's dollar on medical care because he or she won't need much medical care.

The insurance industry accomplishes this through two main policies. One is policy "rescission." They look carefully to see if a sick policyholder may have omitted a minor illness, a pre-existing condition, when applying for coverage, and then they use that as justification to cancel the policy, even if the enrollee has never missed a premium payment.

Rescission is important to the business model. At a recent House Subcommittee on Oversight and Investigation meeting, Rep. Bart Stupak, the committee chairman, asked three insurance industry executives if they would commit to ending rescission except in cases of intentional fraud. "No," they each said.

Potter also emphasized the practice known as "purging." This is where insurers rid themselves of unprofitable accounts by slapping them with "intentionally unrealistic rate increases."

By kimsmom
Posted August 29, 2009 at 9:16 am
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URGENT. ULTRASOUNDS WILL NOT ASSURE ANYONE THAT THEY DO NOT HAVE THE BEGINNINGS OF OVCA. THE ONLY WAY TO DEFINITELY SEE IT IN TIME, IS A CT.
IF YOU OR ANYONE IS REALLY CONCERNED ABOUT THE USUAL INCREASING BELLY SIZE AND...G.I. OR FEMALE PROBLEMS, AND/OR LOW ABDOMINAL PAIN..GO TO ER AND TELL THEM YOU HAVE A HISTORY OF KIDNEY STONES. THEY WILL DO A CT. IF THEY DO NOT SEE ANYTHING - GREAT! BUT, IF YOU DO HAVE EARLY OVCA, YOU HAVE SAVED THE INSURANCE COMPANY LOTS OF MONEY..AND HOPEFULLY, YOUR LIFE!
SO SORRY ABOUT YOUR MOM.
HUGS AND PRAYERS.

By momanderson920
Posted August 29, 2009 at 1:16 pm
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Insurance decisions can be appealed and the doctor is the one who would need to write a letter of explanation justifying the ultrasound. I used to work for a doctor and oftentimes this worked, not always. But you need your doctor to handle it. I would try it...what do you have to lose.

By youngmom
Posted August 29, 2009 at 3:20 pm
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Designermom, when I was fist diagnosed, there were some things my insurance company initially refused payment for on the grounds that it was medically unneccesary, Momanderson is right - the best way to get it covered is have your doctor justify it. My doctor was great - he had to write several letters and make several phone calls to get some things covered for me, but in the end the insurance company paid for everything. And Kimsmom, a CT scan is no better than an ultrasound in picking up OC. I had a vaginal ultrasound, a CT scan, and an MRI, and all 3 were read to indicate that I had one fibroid tumor in my uterus. I had a hysterectomy because of the problems I was having with that "one fibroid" and that is how my OC was discovered. However, my ovary was behind my uterus and in between was the ovarian tumor. My right ovary was not seen on the intitial ultrasound, so OC was not suspected and on both the CT scan and MRI the tumor appeared to be in my uterus even though it was behind it. I might add that none of the tiny sprinklings of cancer in my abdomen were picked up either.

By zircons
Posted August 29, 2009 at 4:35 pm
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Is there any way you can make a deal with the hospital to pay in small increments if the doctor orders either the ultrasound or the CT? I would also ask the doctor to appeal to the insurance company again.

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