Wednesday, May 16, 2007

second opinion

"Managed care" is such a misnomer. I say this having worked in a claims office for HMOs before I started my current job. I'd roll my eyes as patients complained that surely chiropractic care was covered under their plan? I'd deny claims with wild abandon, as we were taught to do, that didn't meet the strict criteria set forth by the plan. Maybe that should be The Plan, as everything we did centered around an almost cult-like atmosphere

At the time, the concept of HMOs was entirely new to me, and I learned everything about them along the way. My family had a PPO plan, so the thought of having to be referred to see a doctor was foreign to me. That you couldn't just see a dermatologist because you had a rash, you needed "prior authorization" seemed ridiculous.

Fast forward 6 years and I am now an HMO subscriber with my own policy. The transition between PPO and HMO was interesting, but because of my former job I felt like any questions I would have had were answered. I haven't had too many issues.

Until I went on vacation and got sick. I went to the doctor I used to see when we lived on Maui, when we had a PPO, knowing that he wouldn't accept my insurance, but that I'd be able to submit it for reimbursement upon my return. After all, I was out of state, it's not like I had a lot of options. This doctor is awesome, and because it's half urgent care facility (or at least it used to be) and half regular doctor's office, he keeps irregular hours. Like when I went to see him on a Sunday. Not normal business hours for a doctor's office, but I got to reap the benefits.

So the bill, with medication, came close to $300. Figuring a) you can't put a price on health, and b) that my insurance would reimburse me, I didn't have any trouble forking my credit card over.

Fast forward to returning from my trip and trying to get my $300 back from my insurance company. According to them, I should have visited an emergency room and that's the only way the claim would be covered. The truth of the matter is that I wasn't sick enough to occupy a spot in the ER and would have felt guilty doing so.

So now I'm $300 poorer and pissed off at my insurance company. (And p.s. -- I'm still sick!)

Don't think I'm not going to appeal their decision.

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