Category Archives: Obamacare

Patient Protection and Affordable Care Act Update

I have been getting calls, and now collection letters, regarding an unpaid $81 toward a discounted $131 deductible (a savings of $119 over the list price!)  from a quick pre-colonoscopy consultation I was required to have last October.  I’d been told the procedure was fully covered as preventive care, except, apparently for the visit to the gastroenterologist to shake his hand and give his receptionist my $50 copay the week before.  There were also a few hundred in fees, it turns out, because a polyp had been sent to the lab for analysis.  Lab fees, obviously, have nothing to do with the preventive procedure.

“Why am I required to pay $100 by check on the day of the procedure if the procedure is fully covered by the premium I pay every month?” I asked the woman at the hospital.  She didn’t know, but the procedure would not be done without the payment.  I paid.

Fast forward eight months, calls to the insurance company regarding charges, conversations with the doctor’s office.   Eight months of demands and threats and finally another letter from a lawyer who specializes in collection.    My position is that I’ve already paid the $81 in the form of that $100 check nobody can seem to justify.  

Out of the blue, yesterday, another envelope from the hospital.   Without any explanation, a check, written out to me, for $100.

To Prove I Was Not Depressed

To prove to someone who loves me and worries about me that I was not depressed, I made a doctor’s appointment I had been putting off making.  

My ailment was digestive, or rather, excretory, and had not been particularly terrible, but was a change for the worse and had persisted for a few weeks.  She kept urging me to see a doctor, rather than find out, God forbid, I had colon cancer only after the disease had too firm a foothold to dislodge.  Since I kept mentioning it, she kept reminding me, with mounting exasperation, that I should see a doctor.

My doctor was on vacation, but his nurse practitioner would be able to see me fairly soon.   My experience with this woman was mixed, she was defensive, short-tempered and had a wavering attention span.  She asked questions and did not listen all the way through the answer.   She scolded and defended herself instead of cutting to the chase and solving the problem.   I’d felt very mature overlooking what an unlikable person she could be on a previous visit.  My gut told me not to bother with her, but my gut was also giving me problems the internet had no ready answers about.  

In any case, I knew my doctor would probably only refer me to a gastroenterologist.  One of my hesitations of getting involved with doctors was paying unknowable fees of hundreds of dollars to a referring doctor, and even more to a specialist, to have a series of diagnostic tests I’d also have to pay for “out of pocket” though I pay a premium to an insurance company every month.

I purchase Obamacare, a small, deeply flawed step towards controlling health care costs and lessening the unconscionable number of Americans who die for lack of affordable health care.  One frustration of this Great Compromise is that a consumer can’t find out the price of an office visit until the office she or he visits submits a bill to the private health insurance company.  The insurance company sends a copy of the claim to the patient and informs the doctor’s office of the negotiated rate and the patient gets a bill.  I have a folder full of these bills, many of which I am not responsible to pay, some of which are in collection against me.  The difficulty of finding out which I owe and which I don’t is a vexation that is bad for the health of everyone effected by this complicated private health insurance law.

The nurse practitioner spent much of our twenty minute meeting searching the internet for information on an odd symptom I had already researched: pink mucus.  She meticulously typed in every aspect of our conversation for her on-line records but, although bowel conditions are often effected by such things, never asked about changes in diet, circumstance, stress, sleep, mood.  She had never heard of pink mucus in the stool.   She was concerned that she’d never heard of this.  

“Shall I do a rectal exam to see if you have a hemorrhoid?” she asked.

“Would an external hemorrhoid cause this symptom?” I asked.  

“No,” she answered, “but an internal hemorrhoid might.”  

“Would your exam be able to tell you if I had an internal hemorrhoid?” I asked.  

“No,” she admitted.  I declined her invitation for a rectal exam.  My rectum was already fairly sore, in any case, inflamed, in fact.  She advised me to use soft, moist wipes instead of toilet paper and sent me for a blood test.

She had no other advice whatsoever, except to get to a GI doctor ASAP.  I reminded her I’d had a recent colonoscopy (a “fully covered” preventive service they are still billing me for…) and that it was therefore unlikely that I’d developed a serious condition in a matter of months.   I also knew, from my research, that diagnosing bowel trouble was a matter of ruling out a number of conditions and a likely diagnosis of IBS which is famously triggered by stress.  

I was also not looking forward to paying hundreds of dollars to have these things ruled out.  In any case, it didn’t feel like an emergency situation and the symptoms had not become any worse over those weeks.

A snippy phone message arrived two days after the visit urging me to get to the specialist ASAP.  A couple more snippy messages followed, one informed me there was an inflammation shown on the blood work.  Each message urged me to go see the specialist ASAP.   I’d been out of phone range, upstate, and didn’t get these until I got back to the city.  I called the office a few days later and had a copy of my blood test results sent to me.  They were mostly within the normal range and arrived without any accompanying comments.

Punchline # 1:  consciously changed my sloppy diet back to a more regular high fiber one, got some more physical exercise, completed some challenging work that had been dogging me, got a few nights of decent sleep: pink mucus and other symptoms gone, problem solved.

Punchline #2:  bill from Patient Protection and Affordable Care Act for twenty minute visit to distracted nurse practitioner, plus three scolding voice mails: $180.  

Everybody’s got to make a living.  God bless America, y’all.

Shining the Light of Reason

It turns out there is a good reason I am responsible for a few hundred dollars in connection with a preventative procedure 100% covered by the Patient Protection and Affordable Care Act.  Once it was explained to me, it became perfectly understandable.

The procedure is 100% paid for (with only a token $100 payment required from me), a $4,050 colonoscopy that was paid, on my behalf, at the contracted price of $852.  In consideration of this deep discount, the PPACA also protects the interests of doctors shorted by insurance company payments as well as the insurance companies themselves.

The PPACA requires a pre-colonoscopy office visit, something not previously required.  This visit with the specialist is subject to a $50 copay.   The doctor may charge up to $250, but the patient will only be responsible for the difference between the copay and the contracted price for this required visit, $131.   So the bill for the additional $81 is correct and the full responsibility of the patient.  The $131, which goes toward the $1,750 deductible, reflects another deep discount, almost 50% off the sticker price.

The diagnostic code 2113 was properly entered by the doctor’s office, even though no diagnosis was involved.  It’s called a diagnostic code, sir, and you chose a plan with a deductible, even if it was the only plan offered at your income level.  Pay the bill.

Procedure code 88305, level five, means that the patient, and not the insurance company, is responsible for the other half of the pathology charges related to the colonoscopy.  If the preventive procedure had not discovered any abnormalities requiring a pathologist, the patient’s preventive care would have been completely without additional cost, except for the $131 deductible and the $100 pre-colonoscopy fee.

As my father so often reminded me, I’d complain if I was hanged with a new rope.  The main thing is– what a great step forward Obamacare is for every American patient everywhere and how generous the discounts it affords.   And as President Barack Obama himself would say:  what are you going to do about it anyway, bitch?

Here we go, the ACA, in a nutshell

Haven’t discovered how to enforce my right not to receive apparently fraudulent bills from health care providers (so far I’ve had a few hundred dollars for duplicative demands for payment dismissed, after calls to billers).  But part of the difficulty with the law is put in context by the following:

The Patient Protection and Affordable Care Act (PPACA), codified as amended at scattered sections of the Internal Revenue Code and in 42 U.S.C. commonly called the Affordable Care Act (ACA) or “ObamaCare“, is a United Statesfederal statute signed into law by President Barack Obama on March 23, 2010.  (Wikipedia)

When I wrote the other day that it was written by the health insurance and pharmaceutical industry to benefit those industries, I was lacking the name of the author of the ACA.  A friend found it for me in remarkably short order.   Her name is Elizabeth Fowler and she worked closely with former Senator Max Baucus between three separate stints in the industry.

Here’s a good article about Elizabeth Fowler, health industry insider and primary author of the PPACA, now back working for Johnson & Johnson — with a very worthwhile five minute video editorial by Bill Moyers at the end of the article.

(Thanks to JDS for sending link to article on Liz Fowler and her stinking ilk)

If you prefer an article in the New York Times, read this.

A bit more about Ms. Fowler and her former boss, Mr. Baucus:

Fowler’s career in Washington stretches back more than a decade, when she first left a private sector hospital group in Minnesota in 2000 to join the Health Care Financing Administration, a federal agency now known as the Centers for Medicare & Medicaid Services (CMS).

By the following year, Fowler had landed at the powerful Senate Finance Committee, working on health care issues for Montana Democrat Max Baucus. Lobbying records show that Fowler stayed until 2006, when she departed for a two-year stint at health insurance company WellPoint, only to return to the Senate in 2008, again working on health policy for Baucus.

When it comes to health care, and health lobbyists, Baucus isn’t just any senator. Since 1998, he has collected more than $5.1 million in campaign contributions from the insurance, pharmaceutical and nursing industries, making him one of the health care sector’s most heavily backed lawmakers.

 (the rest of the article is here —->)  yawn, yawn 

The Difficulty of Even Researching the ACA

The Patient Protection and Affordable Care Act is one of those taunting, ironic names government sometimes gives to things.   That patients are not protected from billing practices that violate the law, that the rights that must be protected are not discoverable without massive effort (my own efforts continue, I’ll let you know when this lawyer discovers the section of the massive and complicated law that outlines these inviolable rights)  that there is no place to have a clear adjudication of the many violations of protected rights, and that the health care is not necessarily affordable add to this citizen’s sense of being taunted.

My frustration reminds me of how angry I felt, the day after millions gathered across the globe, and I was one of hundreds of thousands in New York City out protesting on an arctic day, threatened by NYPD on horseback and kept blocks from the U.N., when then President Bush announced that we would invade Iraq in a war based on endlessly repeated lies and the profit calculations of a few powerful corporations.

“Those stupid, cynical, Nazi motherfuckers!”  I remember thinking as Operation Shock and Awe began in my name.  That was just my frustration speaking.   The architects of that illegal war were not stupid– they made a ton of money whacking that hornet’s nest and destabilizing an already volatile part of the global warming puzzle. Nobody whose actions lead to amassing a fortune can be called stupid, not here.   Cynical?  Perhaps, you could make a good argument there, but there is no law against being a cynic.  

Nazis?  Well, to put things into perspective, the Nazis started a war that killed tens of millions while deliberately exterminating many millions in specially designed death camps.  The Bush Administration killed only about 500,000 Iraqis, many of them, undoubtedly people who hated America.  Moreover, not one of these Iraqis was killed in a death camp, there simply were no death camps.  Perhaps 1% of that number of Americans were killed liberating Iraq from a monster, so already comparisons with the Nazis seem a bit strained, don’t they?  

The Bush Administration, as President Obama finally admitted “tortured some folks”, but even a quick comparison makes one realize how unfair it is to call them Nazis.  They really believed they were doing the right thing!

Maybe Max Baucus, whose committee wrote the Patient Protection and Affordable Care Act so reviled and attacked by the President’s legions of bitter enemies believed the same thing.  The health insurance industry, and the pharmaceutical industry, two huge supporters of the long-time senator, would be badly hurt by a single payer system that would allow a few hundred million Americans to bargain for health services that could be fairly regulated by the federal government.  Where is the freedom in that?  Stinks of Socialism and restraint of the free market, don’t it?

Don’t believe me, here’s what Wikipedia says about Mr. Baucus  and the practical conflict of conscience * he endured while overseeing creation of the immensely dense Patient Protection and Affordable Care Act.  In a five year period prior to beginning his work on Obamacare he took in almost $5,000,000 in campaign contributions from the industries the new law would either make much more profitable or rob of a good share of its profitability.  Doesn’t take a genius to put the sad facts together.

What I’m looking for, and haven’t found yet, in addition to a clear cut answer on whether I should pay bills for hundreds of dollars for a covered preventive service, on top of my $471 monthly premium, is the name of the woman, one of the primary authors of the grotesquely tangled ACA,  who went through the revolving door President Obama announced would be closed, and returned to work for the health insurance industry at an annual salary in the millions.   Can you say “job well done”?   Good thing Mr. Obama closed that revolving door, as important as his closing of Gitmo.   Ask the prisoners there who are being force fed with tubes down their throats how that closing of Gitmo thing worked out for them.

Sarah Palin winks atcha.

 

 

* Baucus has been criticized for his ties to the health insurance and pharmaceutical industries, and was one of the largest beneficiaries in the Senate of campaign contributions from these industries.[40] From 2003-08, Baucus received $3,973,485 from the health sector, including $852,813 from pharmaceutical companies, $851,141 from health professionals, $784,185 from the insurance industry and $465,750 from HMOs/health services, according to the Center for Responsive Politics.[49][50] A 2006 study by Public Citizen found that between 1999 and 2005 Baucus, along with former Senate majority leader Bill Frist, took in the most special-interest money of any senator.[51]

Only three senators have more former staffers working as lobbyists on K Street, at least two dozen in Baucus’ case.[51] Several of Baucus’s ex-staffers, including former chief of staff David Castagnetti, are now working for the pharmaceutical and health insurance industries.[52]Castagnetti co-founded the lobbying firm of Mehlman Vogel Castagnetti, which representsAmerica’s Health Insurance Plans Inc, the national trade group of health insurance companies, the Medicare Cost Contractors Alliance, as well as Amgen, AstraZeneca PLC and Merck & Co.Another former chief of staff, Jeff Forbes, opened his own lobbying shop and to represent thePharmaceutical Research and Manufacturers of America and the Advanced Medical Technology Association, among other groups.[citation needed]

A statistical analysis of the impact of political contributions on individual senators’ support for the public insurance option conducted by Nate Silver has suggested that Baucus was an unlikely supporter of the public option in the first place. Based on Baucus’s political ideology and the per capita health care spending in Montana, Silver’s model projects that there would be only a 30.6% probability of Baucus supporting a public insurance option even if he had received no relevant campaign contributions. Silver calculates that the impact on Baucus of the significant campaign contributions that he has received from the health care industry further reduces the probability of his supporting a public insurance option from 30.6% to 0.6%.[53]

In response to the questions raised by the large amount of funding he took from the health care industry, Baucus declared a moratorium as of July 1, 2009 on taking more special interest money from health care political action committees.[54] Baucus, however, refused to return as part of his moratorium any of the millions of dollars he has received from health care industry interests before July 1, 2009, or to rule out a resumption of taking the same or greater health care industry contributions in the future.[54] His policy on not taking health care industry money reportedly still allowed him to accept money from lobbyists or corporate executives, who, according to The Washington Post, continued to make donations after July 1, 2009.[54] A watchdog group found that in July 2009 Baucus accepted additional money from the health care industry in violation of his own self-defined moratorium terms, reportedly leading Baucus to return those monies.[55]

source

Obamacare 101

If you receive health insurance under the Affordable Care Act (“ACA”), Obamacare, you already know that it has all of the elements of a corporate scam.  If not, the jury would seem to still be out.   I’m here to tell you that the verdict is in.

I have a politically progressive friend who reads the Wall Street Journal every day.  He argues that the ACA has been a great step forward.  It covers millions more uninsured Americans than ever before and is beginning to rein in runaway medical costs.   As a participant in the ACA, and no fan of the Wall Street Journal, I can tell you from direct experience how closely Obamacare resembles an insurance industry scam.  

On the plus side first, it can’t be denied that eliminating the loophole of “pre-existing conditions”, the term that enabled American health insurance companies to deny insurance if you were ever sick with a particular disease, was welcome, and long-overdue.   There are other good features, no doubt. The perfect should never become the enemy of the good, as the president has said, but for the most part the ACA, that great free market compromise with comprehensive health care reform written primarily by and for the insurance industry, profits mainly that industry.   Like many other boons applauded by the Wall Street Journal, it involves large profits for the canny few at the expense of the clueless many.  

The opacity of the 900 page ACA is one of its most notable features.  If your rights and remedies are hard to discover, most people pay the bills they are sent and kiss their rights and remedies goodbye.

New York State set up a Health Care Marketplace at the earliest possible date.   We were all in for Obamacare.  Visit the New York State of Health website and you will marvel at the opacity of the consumer-friendly system.  From the difficulty of signing in (that’s called Get Started, by the way, no matter how many times you’ve already gotten started), to the lack of easily navigable plan details, to the absence of a clear statement of what the ACA is, or what it guarantees, to the almost completely useless help number (“we are experiencing more than the usual volume of callers, your business is very important to us”) you will see enough to discourage the casual seeker of health insurance from persisting there.  Also, enough to deter anyone looking for the rights guaranteed by the law in clear, unequivocal language.

“Preventative services are 100% covered,” the helpful woman at the NYS of Health assures me, after only 35 minutes on hold.  I ask her where I can see a list of these covered services, since I’ve already paid $150 in co-pays towards my recent colonoscopy and am being dunned, and threatened with collection letters, for an additional $281 connected with this preventative service.   She isn’t sure where I can find that language, the NYS of Health Marketplace only sells the plans, they don’t actually administer them or oversee the individual insurance companies.  

This particular woman is great, sympathetic, smart.  I kick myself that I did not get her name.  We look together for language that says I’m entitled to have my colonoscopy paid for 100% under the ACA, for my $471 monthly premium.  I find, several screens later, in only 4 or 5 clicks, this page, under Resources, and on the pull-down menu there’s a link for Using Your Plan, that eventually takes me to this, at the bottom of that page:    

Sep 26, 2013

Covered Benefits and Out-of-Pocket Costs for 2014 Standard Health Plans

And I read, under What Are Essential Health Benefits, number 9, the closest I will find to any kind of confirmation of this seemingly simple yes or no fact that preventive services are not subject to any deductible, to wit:  

Prevention & wellness services and long-lasting disease management

“You are entitled to be repaid that $150 you already paid for a covered service.  If your insurance company is making you pay any fee in connection with a colonoscopy they are not in compliance with the ACA and you should hold their feet to the fire,” this bright woman, a former health insurance industry appeals expert, tells me firmly.  

She informs me, in answer to my question, that the Department of Financial Services (“DFS”) is the state agency that holds insurance companies accountable for compliance issues.  She gives me their 800 number (800-842-3736  M-F 8:30-4:30).   I ask why there is no information about that on the NYS of Health webpage. They are discouraging frivolous complaints, she explains, since so many people are having problems with the ACA.  Not publishing the complaint number reduces the amount of angry callers making unfounded complaints before they have followed up with their individual insurance plans to make sure the insurers are out of compliance before calling DFS to lodge a complaint.

Makes me think of President Obama’s laudable campaign promises about transparency in government, protection of whistle blowers, and robust protections for consumers. Clear knowledge of one’s rights, after all, is a precondition to exercising them.   Few things are more important to the proper functioning of a just and accountable democratic republic than government transparency.   Few things are more useful to exploiters, despots and profiteers than the secret concealment of devilish details that might galvanize righteous opposition.

I recall the president’s campaign rhetoric and think of the Obama administration, the most opaque in our history, whatever else one might say about it, and my jaws clench. And I have to say, between Obama and Bush, dealing with the latter is much less soul crushing to an idealistic citizen than listening to the glib eloquence of the Equivocator in Chief, great lover of justice and defender of the common citizen that he is.