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Saturday, April 04, 2009

"Imagine waking up one day and all your medical decisions are made by a central, national board," says one Richard L. Scott, who seems intent on bashing Obama's plan for a health care re-do.

Before we get to Mr. Scott (see New York Times article "Health Critic Brings a Past and a Wallet," Thu, Apr 2, 2009), I'd like you to ponder that sentence. First, waking up at all is a nice thing these days, given the state of care in this country. If you're a pregnant female, a child, or an elderly person, or anyone with a chronic condition such as diabetes, debilitating pain, heart disease, etc, then God help you. Doctors are too busy with insurance issues to care too much for you and your problems. And they are too afraid of you to actually get to the bottom of things. Afraid you'll end up suing them, so they end up testing you for anything, but don't want to say too much, or spend time with you listening. Just test, bill, test, bill.

But let's say you've succeeded in waking up one more lovely day. What about all those medical decisions? Well, you're doc makes them, right? Um, no. Your insurance company—if you have one (if you don't then you don't see a doctor anyway because you can't afford one)—makes them. What medication are you on? Your insurance company gets veto power over every prescription your doctor writes. Same with the tests. Even the time spent with your doctor ends up being determined by the insurance mafia.

Now comes the real point of Mr. Scott: that nasty national board. But wouldn't it be more transparent, wouldn't it in the end be easier to navigate one board…than the thousands out there now? Does anyone even have an idea on how to navigate their way around the insurance industry today? I don't, and I work with these bleeping people daily. Believe me, you don't want to call these people for anything. I'd much rather have one agency to call, one board to petition, one representative responsible.

I'll give one example, which just happened yesterday, or rather over the last few days, as it tended to drag on and on. Joe Shmo comes in with two expensive prescriptions for inhalers for his mother, who has a bad case of COPD (Chronic Obstructive Pulmonary Disease). I'm talking expensive. But necessary. Anyway, she has Medicare part D, and Medicaid. No problem right? Problem. What plan did she have? Wellpoint. But the card was not forthcoming yet. OK. We'll call Wellpoint (didn't want to but did). After some twenty minutes (but everyone else waited so patiently right?) we have information that Joe Shmo's mom doesn't seem to have Wellpoint at all. At least that's what Wellpoint said. Not that you can trust the information you get from any of these companies. Sometimes it is just who you speak to at any given time (see previous blog).

So we bill to the secondary, Medicaid. Medicaid won't pay unless the primary pays first. Nah, nah, na-nah nah. Joe said to call the local Medicaid gal. Said she said just call her if there's a problem. So we did (didn't want to because, well, everyone was still being so patient but for how long?). It became clear that this person didn't know her job—not exactly a rare occurrence, I find, in dealing with Medicaid agencies. She basically said to call Wellpoint and everything would be OK. Joe said he'd take it from here, and thanked us for our efforts. Back to work everybody!

Next day the process repeated, as Joe said he'd talked to the Medicaid gal and she said everything was finally working. Except it wasn't. More calls. More perplexed discussions with Joe. Another day goes by.

Joe calls yesterday and says it all is supposed to work. Finally. Except it doesn't. More calls. I finally get some information though that his mom doesn't have Wellpoint anymore, that she was switched to Silverscript (unbeknownst to everyone involved, including the government!). OK, so I call the Medicaid gal and ask for the billing info. She doesn't know a thing. Can't even give me a phone number. Useless. But I do get some info from another Medicaid worker who tells me that she put through some extra fancy prior authorization for Joe's mom and that I could now just bill the State and it'd go through. At this point I told her to stay on the line, because I was sure it wouldn't work and I wanted somebody I could yell at when it didn't. But it did! Something actually worked in this lame-brained system of ours! Eureka!

And you know what else? Joe actually thanked me for my efforts. Usually people just walk away cursing, under or over their breaths.

But just imagine, if you will, a system NOT controlled by ten thousand medical boards across this country, but by JUST
ONE! O the dream! The dream!

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