Health Insurance Is a Scam

Billing Nightmares 

My daughter Maggie has type 1 diabetes. She's had it for nearly a decade. Her treatment has been substantially the same for the past six years. She has an insulin pump and a continuous glucose monitor that, at some point, were linked to provide her with "hybrid closed loop" insulin delivery, which is fancy way to say that the glucose monitor feeds her blood sugar data to her pump so that it can automatically adjust her insulin dosages to correct for high or low blood sugar. The technology is pretty nifty. 

It's also very expensive, and we have had Platinum-level health care plans in order to pay for this. They are also not cheap. Last year, after double digit annual increases for, like, forever, our annual premiums were nearly $30,000. 

For this staggering amount of money, more than the totality of a full-time minimum wage job, you would think we would not have a problem with getting coverage for a well-understood and well-controlled chronic disease that Maggie has had for literally the majority of her life. 

You would be wrong.

I have been calling a medical supply company (Edgepark) and my insurance company (Highmark, formerly Blue Shield of Northeastern New York) about bills beginning LAST MARCH, trying to get them to agree to charge me the correct co-payment for her CGM supplies: a transmitter and glucose sensors that she needs replaced four times a year. They have billed and process the claims correctly two of the four times. The other two of the four times, they have counted them as "durable medical equipment," which requires a 50% copayment, instead of "diabetes supplies," which is a $15 co-pay. This is a difference of THOUSANDS OF DOLLARS. 

I called Edgepark in perhaps May(?) and explained that they had billed the CGM sensors incorrectly as durable medical equipment instead of diabetes supplies. They told me to call the insurance company because they couldn't do anything without an updated explanation of benefits. I called the insurance company and they agreed that, yes, I am correct. It is diabetes supplies and $15/item. They called Edgepark and supposedly fixed it. Nothing happened. 

Pretty sure I called every couple of months, but finally in August, I started taking notes on my calls. August 18 call, nothing fixed. September 9 call, nothing fixed. October 10, the insurance rep called Edgepark, sent all the claims back for adjustment, and Edgepark was supposedly going to be refund my $466.25 overpayment in "hopefully fewer than 30 days.  

December 8 call, same Highmark rep, but nothing fixed. She recommended I check Jose's member portal—I'm the one who deals with all this shit, but since it's through Jose's job, he is the "policy owner" so I can't see anything—to see whether the claims were re-billed. 

I got two corrected EOBs, and another that is wrong, also from LAST MARCH but with a different Date of Service than the one I overpaid in the first place.

I went to the Edgepark website and listed all the orders and cross-referenced that with my credit card charges. The dates don't match up very well because, in one of those brilliant moves of "economic efficiency," Edgepark has an outside billing service. Last year I paid Edgepark $706.95, including two small, odd mystery charges just to keep getting supplies—every single order should have been a multiple of $15. (I suspect that there were small late fees charged because they would sometimes charge my credit card at time of order then also send a bill for the charge, which I would ignore for a while then have to call and have fixed.) According to their website, I ordered 14 items, which should have been a total of $210. They owe me almost $500. 

Instead, I'm getting hounding emails and calls from the medical supply company, telling me I have a balance of $668.25, and would I like to set up a payment plan? I DO have in hand a corrected EOB for one of those bills. But even more EOBs that say I owe the OTHER 50% co-pays.

It's maddening that Highmark blames Edgepark, and Edgepark blames Highmark. Highmark says Edgepark is using the wrong "pointer code," while the snippy woman from Edgepark billing insisted that Highmark changed everyone's policies nationwide "without notifying them" to cover CGM supplies as a pharmacy benefit rather than a medical benefit and that is what is causing the billing/claims problems. 

I don't know, and I find it insane that sometimes they get it right. Like, who is fucking up and when?

That is problem ONE. 

It's Easier NOT to Use Insurance

Problem two is this: It's easier to get healthcare from sketchy websites than to use my freaky-expensive insurance.

Even with freaky expensive health insurance, it takes four to five months, or, in the case of my doctor, eleven months, to get an appointment with a provider. I'd say doctor, but Maggie's "endocrinologist" is actually not a doctor, but some other sort of (admittedly highly trained and knowledgeable) professional, and the person who sees me at the dermatologist's office is a physician's assistant. Right now, I actually can't get an appointment with my doctor, who is on medical leave and, judging by the way he looked last time I saw him, is probably somewhere in the world dying, may his cranky, arrogant, self-important self Rest In Peace. But my doctor's office hasn't told me that I need to find a new provider. I guess they're still hoping he'll come back? However, they also will not renew my prescriptions...because...I haven't been to the doctor. Catch-22, anyone?

So for my rosacea and depression, it's actually easier and faster to skip my expensive-ass insurance and my unavailable providers, and get prescriptions for creams and Wellbutrin from sketchy sites on the Internet to whom broke doctors with exorbitant medical school debt lend their names and medical license numbers. Evidently, I could also get hair loss creams and pills for erectile dysfunction while I'm there. Huzzah!

My insurance premiums are nearly $30,000 because, rather than providing health care for humans, the American health insurance industry exists to create chaos, paperwork, billing errors, and above all, executive pay and shareholder value.