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The Rainmaker is You, Navigating the Hazy Maze of Health Care Coverage

by on February 23, 2015 6:15 AM

After a week of fun and sun in South Carolina that included meals in restaurants, a day in a rented boat on the water, and plenty of sunscreen, we noticed that our oldest daughter seemed to be having a reaction to something.

Her forehead started to swell. Over the course of a few hours, it really started to puff out.

As we packed the cars for the ride home, we suggested she take some Benadryl and let her friend drive the car home.

When we stopped in Virginia for dinner, the swelling in my daughter's face had spread down from her forehead to the bridge of her nose, her eyelids, her cheeks and her lips. Despite several doses of over-the-counter anti-allergy medication, her body continued to react to whatever she had ingested, been exposed to or had applied to her face.

We began to worry about the swelling potentially impacting her ability to breathe. It was clear that she needed to be seen by a professional.

With my health savings account "credit" card in hand, her friend drove my daughter (still covered under my insurance because she is under 26) to the nearest emergency facility which we found using a GPS search on one of our cell phones. She paid the co-pay as outlined in our insurance policy and then received an IV with fluids, prescription doses of anti-histamines, and a take home prescription for more medication.

After several hours of on-site treatment, she was discharged and sent on her way. She ended up missing several days of work after the incident because her face and eyes were so swollen she had difficulty seeing.

That was the summer of 2013. In December of 2014, I received notice from my health insurance company that payment for that emergency service was "denied" and that I owed $921 dollars above the $100 co-pay that we paid at the emergency facility. A day or two later, I received the bill for the $921 from the emergency facility.

I was shocked. We had paid the co-pay as instructed. Isn't emergency care covered under my health insurance plan? It takes almost 18 months to get a denial and then a bill? Do I have any recourse?

It reminded me of the John Grisham book and then movie "The Rainmaker." The premise of the story was that insurance companies routinely deny a significant number of claims just to buy time and with the hopes that the consumer is too stupid or uninformed to appeal the decision.

I reviewed my insurance policy, gathered up all of the information that I had including receipts from the emergency facility visit, and sent copies and a letter in a packet to my insurer requesting an appeal of the decision and then notified the emergency facility that we were appealing.

I was pleased to learn this week that their decision to deny payment has been reversed. They determined that we had "no choice" but to visit an out of network provider. This past weekend, I received a check made out to me for the full amount from my insurance company (which I promptly sent to the facility lest I get tempted to go shopping at TJ Maxx).

In health care, it's all about self-advocacy.

With a family of five, we have had an assortment of illnesses, injuries, mishaps and diagnoses over the years. It sometimes feels like a full-time job to not only advocate for appropriate assessment and treatment of our routine issues but also for payment for that treatment through our health insurance. I can't imagine what it is like for families who have serious issues. Of equal concern has been watching my mother (and my father and grandmother before their deaths) try to navigate a very complex health care and health insurance system.

The cost of health care has skyrocketed in recent years. Insurance costs have likewise exploded exponentially. Each policy involves co-pays, deductibles and a moving target for what is covered. The documentation (coding), pre-authorization system and diagnostic criteria for what/how much treatment and who pays for it sometimes depends on who is reading the paperwork we filled out and making sure we have filled out the right paperwork.

Why is the system so difficult? What happens to people who are ill or confused or who don't understand? What about those people who don't have a support system to assist them through the process? What happens to those people who can't or don't read the fine print on either their insurance policy or their bill and end up being financially crippled by medical bills, collection agencies and a system that seemingly relies on ignorance to save money?

Health insurance is difficult for most people to understand.

The lesson is don't take no for an answer. It's important to save every piece of paper and every receipt. It's important to read or have someone who can read and interpret the documents that explain what each policy does and does not cover. Insurance companies, medical facilities and other entities, including perhaps your employer, offer patient advocates and/or other mediators who will assist with the review and appeal process. Communication with the provider and with representatives of your insurance company can save a lot of time and effort.

I value my insurance benefits and am grateful to have coverage that takes care of me and my family. I am thankful that my employer offers health insurance and agrees to share the cost with me. The lesson learned is for health insurance to work, you have to work it. Make sure to read the fine print and to advocate for yourself and for your family.


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Patty Kleban is an instructor at Penn State, mother of three and a community volunteer. She is a Penn State Alumna. Readers of State College Magazine voted her Best Writer of 2010 and 2012. She and her family live in Patton Township. Her views and opinions do not necessarily reflect those of Penn State.
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