Posted on 09/11/2009 12:04:35 PM PDT by Diana in Wisconsin
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.
By the way, a few months after I received the money MegaLife owed me, they went out of business. I can only hope Obama's reforms bring the rest of them to their knees.
Yep. That'll help, LOL! She's really going to find herself in a 'hazy DMZ' when Government runs things.
Dork.
Plus it grows like a weed here, so I don't have to worry about my copay.
She’s nutz if she thinks a gummint bureaucracy will be less hellish than an insurance bureaucracy.
We have trouble with Blue Cross too when we have an out of PPO claim. We usually win on appeal. It helps to be a proficient nasty letter writer.
it would probably be cheapest for everyone if she would just cheer up.
I call this as BS. I’ve had bouts of depression since I was 17 and I’m 53 now. I have been insured through the years by Prudential, Humana, Blue Cross, United Health Care, WPS, and a couple of smaller insurance companies. All of them covered my doctor visits and medications exactly the same as they did for any other medical issue I had. I have never been refused coverage due to a pre-existing condition by any of these health insurers either.
Its bad enough liberals are posting these lies but why do we have to repeat them here?
She mentioned a ‘manic’ episode. You don’t get those with ordinary depression. I think she’s got other issues.
Look sister, I’ve suffered from depression from a very early age. I had some counseling once a week and it was pretty useless because they were not treating me at the time for depression. Just my anxiety.
You can get a 3 month supply of any of three anti-depressants at Wally’s for $10, or one month for $4. I pay $27.95 for my anti-anxiety/panic attack meds for one month. That’s basically cheaper than an insurance payment. And I see my regular physician once every 6 months. That’s about $45.
If you don’t have insurance you can get Gyn exams and mammograms through the Susan Komen organization for nothing. They are amazing at what they’re doing.
Obama is not going to fix your problems, honey. If anything he’ll make your depression worse as you wait to be able to see a doc to get your meds.
Did a trip through that office once for about 6 months ~ really instructive. You learn a lot about folks ~ particularly this kind.
You can learn about this stuff at it's own website: http://www.effexorxr.com/#
If, as I suspect, this lady is epileptic (else why is she keeping a detailed diary of her daily events) there are some special warnings she should know about when using Effexor.
It also solves the problem if you stay in network. She chose to go out of network and clearly knows enough about her policy to understand the consequences. She made a conscious decision and is paying the price. She is just using this to make a political point. I love the folks who want the reform because they don’t get enough now.
I was listening to Air America the other day. Someone called in to say he doesn’t see why people don’t like government-run Medicare. He was a teacher with great insurance but then he took another job and it was too expensive for his wife to be covered too, so she remained uninsured until she became pregnant. Then she signed up for Medicaid and they’ve been really, really happy with it. [And it’s just the mean, greedy conservatives who don’t care about people who are trying to make other people suffer.]
Every now and then I tune into AA and listen for about 3 seconds before I can’t stand it any more. This is pretty typical of the callers they get, as far as I can tell.
This lady (who has been suffering from “Depression” since the age of 12) needs to just snap out of it and act like a grown up. I’m not convinced depression is actually real. Don’t we all sometimes feel a little blue?
Depressed stupid woman. What did people do before the 20th century? They dealt with it.
“...it would probably be cheapest for everyone if she would just cheer up.”
LOL! Must be doubly depressing being an 0bama voter these days...the End Days just can’t come fast enough for those folks. ;)
“It’s bad enough liberals are posting these lies but why do we have to repeat them here?”
To expose and mock them, Silly. :)
It's going to be doubly horrid ~ the worst of both worlds.
Deal with it lady, like I deal with my kleptomania. When ever it becomes to tough to handle, I just take something for it.
You stole that line from me. ;-)
It seems to be associated with a chemical imbalance or deficiency in the brain.
It's like ADD, though -- you have a smaller core group that really has the disease (and believe me you know them when you see them) and a bunch of people in a grey area or penumbra who think they may have it or wish they or their child has it (so they can fix it with meds). Because the meds often work amazingly well.
I was just thinking - she’s been depressed since 12? And she’s in her 30’s now? I guess “psychology” just can’t cure depression. Maybe, and correct me if I’m wrong, but isn’t depression simply the natural state of mind of a mediocre person who thinks only of herself and how she’s feeling all day long?
Well, when you put it that way...count me in!
I’ve been reading that ADD is a big fraud too! I’m not saying I’m right, but really? Can’t this lady just join a gym and get her body into shape? My lady psychologist friend told me it’s impossible to be depressed while working out. Just think of the abs this lady could develop?
Disclaimer: Opinions posted on Free Republic are those of the individual posters and do not necessarily represent the opinion of Free Republic or its management. All materials posted herein are protected by copyright law and the exemption for fair use of copyrighted works.