Category Archives: Obamacare

Rewrite of To Whom it May Go Fuck Yourself

I came to realize the previous draft was lacking in at least two ways.  It was focused on the mind-fucking Patient Protection and Affordable Charismatic Presidential Candidate Legacy Enhancement Act, for one thing.  The focus on the soon-to-be repealed PPACA gave the whole letter a sour overlay of mootness.  

Equally important, the letter as written probably wouldn’t have inspired the A.G. to take any action and didn’t set forth the specific action I was seeking.   This one, I think, does better in those areas.

Here’s the rewrite, which is about as good as I can get it at the moment,  After I post it I will go back to gnawing at my ankle:

January 4, 2017

Office of the Attorney General
The Capitol
Albany, NY 12224-0341

Honorable Attorney General Schneiderman,

I’m writing to alert you to a massive consumer protection failure in New York State and to encourage you to take action.   There is no New York State agency where a citizen can pursue a claim of fraudulent denial of medical service against a health insurance company.

The need for state oversight is more important now than ever, with an incoming administration committed to dismantling government regulation in many areas.

I’ve admired the courageous and proactive steps your office has taken against the perpetrators of various frauds and urge you to consider this letter in the context of systemic healthcare-related fraud against a large class of vulnerable low-income and senior citizens of New York State.

Uncertainty about health care, lack of information about costs and the routine denial of medical services without explanation are all stressful. They negatively affect the health and quality of life of those mandated to participate in income-based “bronze” level health insurance plans in New York State.   As detailed below, NYS health insurance buyers are denied any protection against the practices of private health insurance companies, even when the denial of necessary service appears to be utterly fraudulent.    

This consumer protection emergency transcends the current health care scheme under the Patient Protection and Affordable Care Act (“PPACA”).   The president-elect’s threatened repeal of the PPACA makes it all the more essential for New York State to regulate private insurance companies.   The replacement for the PPACA, whatever it might be, will not eliminate the need for protection of vulnerable older and low-income consumers, the need will likely become even more pronounced.

 In googling your mailing address to mail this letter I came across the New York State Health Care Bureau, a couple of layers down on your office’s website. While that office no doubt provides a welcome shoulder to cry on, the citizens of New York State sorely need a regulatory apparatus that can make timely and binding determinations on when insurance companies cross the line into actual fraud against their mandated customers.  

 Of course, the creation of a regulatory agency is a matter for the legislature. A fraud investigation by your office into practices such as the ones described below would highlight the need for state regulation, and give momentum to the legislative process.  

As stated above, defrauded health insurance consumers (patients) in New York State have no forum where complaints can be resolved, outside of the NYS Department of Financial Services, which, it turns out, does not hear such complaints.

The fraud investigator there could not find a word other than fraud to describe the facts I set forth, but urged me to call the NY State Department of Financial Services Consumer Services Hotline. He assured me that they were the specialists in the area of health insurance. The recorded menu at the hotline, which I recognized from my first call many hours earlier, offers no option for resolving issues with insurance companies of any kind.  

On my original call to the Department of Financial Services, a long wait to speak to a representative yielded the number of the proper federal agency to contact.   Calls to the U.S Department of Health and Human Services are robotically routed to a NY State number that is, sadly, the office of Temporary and Disability Assistance, where some helpful party connects you to a fraud hotline, which turns out to be at the office of the Medicaid Inspector General, where the office of legal affairs is also sympathetic, but unable to help, and so forth.

 As for the PPACA, I understand that it was drafted by Liz Fowler, a career health industry insider who went on to a senior executive position with Johnson & Johnson immediately after her work on the PPACA was done. I‘ve witnessed the many attempts to repeal the law and thwart its implementation, rather than fix any of its original flaws, as most other complicated laws are tweaked and improved over time. Even so, the lack of any provision for oversight of corporations participating in the PPACA by New York State is grotesque. To a sixty year-old cardiac patient unable to see a cardiologist now for many months, the lack of oversight may also be deadly.

Although the situation I’m complaining of is personal and extremely aggravating, it is sadly typical. I’ve commiserated with many others who suffer under similar insurance coverage.  Erroneous bills are a common, if relatively innocuous, theme.

I receive bills that there is no way to resolve, most recently an invoice for $1,324 for a fully covered sonogram I had in August. The x-ray and kidney sonogram I also had that day were fully covered, the sonogram of another body part was not.   The billing issue was resolved with the insurance company (Empire Blue Cross) and the provider to a zero balance in October. Two months later, the full bill for $1,342 was sent to me again in a Third Notice.  

Nobody at Empire could give me the reason the provider had sent that bill, although the representative, who checked my account and called the provider again, informed me that, this time, it was my responsibility to pay it in full.   She offered to send a consumer handbook for my plan that would fully explain the reason, which she claimed was clearly set forth there, though she could not state it.

There is nobody in New York State to adjudicate this billing matter, outside of a judge on some court one must file an actual lawsuit to appear before, assuming one could find a cause of action.

Empire recently sent me an email warning of termination of my insurance for non-payment of December’s premium two weeks after their email confirmation of my payment for December and January.

More ominously, a patient can be denied medical service without explanation (site-specific provider NPI numbers and proper CPT pre-authorization codes notwithstanding), and there is nobody in New York State you can appeal to, except to the company itself.   Empire Blue Cross “Health Plus” recently sent me to two providers for needed medical services, a cardiologist and a physical therapy facility. Neither provided me with any service. 

I received the site-specific NPI number for the cardiologist, scanned and emailed the back and front of my insurance card, got pre-approval from his office. The consultation was halted ten minutes in and I was informed that my insurance would not cover the visit.   When I arrived at the nearby ‘physical therapy facility’ Empire had referred me to, it was a nursing home.  The director told me the facility offers PT, but only to residents.

The circuit of government agencies I have contacted in vain came full circle with the “consumer help line” the NYS Department of Financial Services Fraud Unit investigator had me call, which I immediately recognized as the very first number I’d called.   Here is a summary of that cul du sac:

NYS Department of Financial Services referred me initially to the US Dept of Health and Human Services which, supposedly, connected me to NYS Health and Human Services, although to an incorrect branch of that agency, the pertinent branch apparently having been merged into the NYS Department of Financial Services which took over all functions of the former NYS Insurance Department as well as oversight of banking and several other discrete* and seemingly unrelated areas.  

The NYS Department of Financial Services, one learns, has sole responsibility for oversight of health insurance companies, as well as all fraud investigations related to consumer fraud against insurance companies, and complaints about the practices of banks and brokers.   Everything but, according to John Marconi, a fraud investigator for the Department of Financial Services, investigations of colorable fraud committed by insurance companies against mandated health-care “consumers” in New York State.

My political and legal conclusions are beside the point. Whatever the reasons, the fact remains that in New York State in 2017, even under the PPACA, citizens whose health is menaced by private insurance company denials are denied any legal process to have these vexing, sometimes life-threatening situations resolved.  

Outside of a possible Article 78 (which government agency would you sue for relief, the Department of Financial Services?) or a class action under a private attorney general or qui tam statute, what is a patient trying to get an appointment to see a cardiologist since August to do under the Patient Protection Act in New York State?   At minimum an ombudsperson, or a few hundred of them, would be a good start.

As I stated above, I’ve followed your career from the start and have admired your principled engagement in the fight against injustice.   To have a legal right that cannot be enforced is to have no legal right.   While certain widespread injustice is accounted by some as a kind of ‘externality’, the lack of legal recourse for denial of purchased health care must not be allowed to stand in New York State.

I will be glad to do what I can to help your office take the first steps towards sorely needed due process for denial of health care for some of the State’s most vulnerable citizens.  I am open to being a plaintiff in any lawsuit the State might want to bring and to testifying in any proceeding.   I look forward to hearing from your office and stand ready to give any other details or assistance your office might require.

 Yours sincerely,

 B.B. Rebozo

 * teachable moment!  The previous draft had idiotically read “discreet”, an error imperceptible to homophone-deaf smell check

discreet:  having or showing discernment or good judgment in conduct and especially in speech :  prudent; especially :  capable of preserving prudent silence

discrete: separate

 

Letter to Whom It May Go Fuck Yourself

Office of the Attorney General
The Capitol
Albany, NY 12224-0341

Honorable Attorney General Schneiderman:

I am writing to enlist your efforts to remedy the lack of state oversight of health insurance companies under the Patient Protection and Affordable Care Act (“PPACA”).

I have admired the courageous and proactive steps your office has taken against the perpetrators of various frauds and urge you to consider this letter in the context of systemic healthcare-related fraud against a large class of vulnerable citizens of New York State.

Defrauded health insurance consumers in New York State have no forum where complaints can be resolved, outside of the NYS Department of Financial Services, which, it turns out, does not hear such complaints.

 The fraud department investigator there could not find a word other than fraud to describe what I detailed, but urged me to call the NY State Department of Financial Services Consumer Services Hotline. He assured me that they were the specialists in this area. The answering machine at the hotline, which I recognized from my first call, offers no option for resolving issues with health insurance companies regulated by the ACA, or otherwise.

 On my original call, a long wait to speak to a representative yielded the number of the proper federal agency to contact.   Calls to the U.S Department of Health and Human Services are robotically routed to a NY State number that is, sadly, the office of Temporary and Disability Assistance, where some helpful party connects you to a fraud hotline, which turns out to be at the office of the Medicaid Inspector General, where the office of legal affairs is also sympathetic, but unable to help, and so forth.

 I understand that the PPACA was drafted by Liz Fowler, a career health industry insider who went on to an executive position with Johnson & Johnson immediately after her work on the PPACA was done. I have witnessed the many attempts to repeal the law, rather than fix any of its original flaws, as most other complicated laws are tweaked and improved over time. Even so, the lack of any provision for oversight of ACA programs by New York State is grotesque. As a cardiac patient unable to see a cardiologist now for many months, the lack of oversight may also be deadly.

Although the situation I’m complaining of is personal and extremely aggravating, it is typical.  I’ve commiserated with others who suffer under similar insurance coverage. Erroneous bills are a common, if relatively innocuous, theme.

I receive bills that there is no way to resolve, most recently an invoice for $1,324 for a fully covered sonogram I had in August. It was resolved with the insurance company (Empire) and the provider to a zero balance in October. Two months later, the full bill for $1,342 was sent to me again in a Third Notice.   Nobody at Empire could give me the reason the provider had sent that bill, although the representative, who checked my account and called the provider again, informed me that, this time, it was my responsibility to pay it in full.  

Empire recently sent me an email warning of termination of my insurance for non-payment of December’s premium two weeks after their email confirmation of my payment for December and January.

More ominously, you can be denied medical service without explanation (provider NPI numbers and CPT codes notwithstanding), and there is nobody in New York State you can appeal to, except to the company itself.  Empire Blue Cross “Health Plus” recently sent me to two providers for needed medical services, a cardiologist and a physical therapy facility. Neither provided me with any service. 

I received the site-specific NPI number for the cardiologist, scanned and emailed the back and front of my insurance card, got pre-approval from his office. The consultation was halted ten minutes in and I was informed that my insurance would not cover the visit.   When I arrived at the nearby ‘physical therapy facility’ Empire had referred me to, it was a nursing home. They offer PT, but only to residents.

The circuit of government agencies I have contacted in vain came full circle with the “consumer help line” the NYS Department of Financial Services Fraud Unit investigator had me call, which I immediately recognized as the very first number I’d called.   Here is a summary of that cul du sac:

NYS Department of Financial Services referred me initially to the US Dept of Health and Human Services which connected me to NYS Health and Human Services, although an incorrect branch of that agency, the pertinent branch apparently having been merged into the NYS Department of Financial Services which took over all functions of the former NYS Insurance Department, as well as the NYS Banking Department.

The NYS Department of Financial services, it appears, conducts all oversight of health insurance, as well as all fraud investigations related to consumer fraud against insurance companies, and complaints about the practices of banks and brokers. Everything but, according to John Marconi, a fraud investigator there, apparent fraud committed by insurance companies against mandated health-care “consumers” in New York State.

My political and legal conclusions are beside the point. Whatever the reasons, the fact remains that in New York State in 2017, even under the PPACA, citizens whose health is menaced by private insurance company denials have no redress.  

Outside of a possible Article 78 (which government agency would you sue for relief?  The Department of Financial Services?) or a class action under a private attorney general or qui tam statute, what is a patient trying to get an appointment to see a cardiologist since August to do under the Patient Protection Act in New York State?   At minimum an ombudsperson, or a few hundred of them, would be a good start.

As I stated above, I’ve followed your career from the start and have admired your principled engagement in the fight against injustice.   To have a legal right that cannot be enforced is to have no legal right.   While certain injustice is accounted “the price of freedom”, the lack of legal recourse for denial of health care must not be allowed to stand in New York State.

I look forward to hearing from your office and stand ready to give any other details needed.

 Yours sincerely,

A. Schicklegruber

Opacity is all that is needed for evil to flourish

One of the stated reasons wealthy American colonists revolted against King George was that they were being subjected to ‘confiscatory’ taxation without representation.  Nor were they offered any meaningful process for redress of their grievances, no way to have their concerns heard and their honest grievances dealt with.  Government secrecy and lack of voice in governance are vexations members of a democracy are not supposed to endure.

A transparent democracy is the best cure for citizen misery, knowing who to contact to solve a problem.  Mr. Obama constantly and correctly reminds us of the importance of transparency in a healthy democracy (even as he does things like classifying the Senate Report on Torture for twelve additional years under the Presidential Records Act — see, and, and). * A transparent democracy is what the Founding Fathers set up, for members of their social class.   The rest of  you bitches?  Go talk to King George.

No requirement in the Patient Protection and Affordable Care Act for a grievance procedure?  Not a problem, bitch.  Just keep quiet, you’ll be dead soon enough, shhhh, shhhhh…. no reason to get excited.  If you had any power, we couldn’t treat you this way.  Be reasonable, little n-word.  

If you’re skillful enough, and manage to choke down your rage and describe the situation coolly enough, maybe you can write something the New York Times will run in the back of their paper of record.  There, there.

Here, here:

Obamacare subsidy income limits

Premium tax credits and cost-sharing reductions have different income limits based on the federal poverty level (i.e., poverty guidelines). They are as follows:

  • Premium tax credits: 100 – 400 percent of the federal poverty level
  • Cost-sharing reductions: 100 – 200 percent of the federal poverty level

Your health insurance subsidy for the current year is based on the previous year’s federal poverty guidelines. That means 2017 subsidies are based on the 2016 federal poverty guidelines, which are available through the Department of Health & Human Services.

The 2016 poverty guidelines show that $12,071 is the poverty threshold for a one-person household. Based on these numbers alone, 100 to 400 percent of the federal poverty level for a single person would be $12,071 to $48,284. However, this person may or may not be eligible for a premium tax credit.

Please be aware that your subsidy eligibility may be impacted by the state you live in due to Medicaid expansion decisions and other savings programs available there.[1] Furthermore, state benchmark plans (i.e., the second lowest cost silver plan) can also impact subsidy amounts and eligibility.[2] You can estimate your premium tax credit using online calculator tools such as the one available through healthedeals.com.

* The New York Times editorial board weighs in  on declassifying the now secret 6,700 Senate Torture Report and Senators Levin and Rockefeller ask Obama, who they quote as saying:  “one of the strengths that makes America exceptional is our willingness to openly confront our past, face our imperfections, make changes and do better” to do the right thing.

 

Obamacare, a last word

I got a phone call just now from John Marconi, an investigator at the NYS Department of Financial Services Fraud Office.   His number came up as 212-555-5555, which can’t be called back, as it happens– it’s not a working number.   I spoke to John for fifteen minutes.  

He listened carefully to my description of being denied services by doctors I was referred to by Empire Blue Baboon’s Asshole, the private insurance company I chose after being assigned my income-based level of PPACA “health care” by the New York State of Health Marketplace.

I read John the 800 number for the New York State Insurance Department I’d been given yesterday, ninety minutes into my investigative work, by the kind woman at the office of the Medicaid Inspector General, who got it from her supervisors.   John explained to me that the NYS Insurance Department had been abolished in 2012, but that the 800 number I’d been given was currently the Department of Financial Services consumer help hotline.  

The governor, while abolishing the Insurance Department in 2012 also abolished the Banking Department.   These abolished agencies were merged into the more streamlined and user friendly NYS Department of Financial Services.   John thought it was a good move, though he admitted it might be more confusing for the public.    He urged me to call that hotline, since his office usually investigates consumer fraud against insurance companies, and fraud by brokers, and things like that. 

I asked him to use a word other than fraud to describe an insurance company sending you to, so far, two doctors and then denying coverage when you arrived for needed medical services, or informing you that an ultrasound of your kidney was covered but that an ultrasound of your pelvis was not.  

He conceded he didn’t have a word that described this behavior better than ‘fraud’, but urged me again to speak to the consumer hotline, they were the experts.  If need be they would refer the matter back to his office.  He modestly told me he was not an expert on fraud under the PPACA (apparently impossible to commit, unless you are a health insurance consumer), though he was the fraud investigator on duty today (they rotate, apparently, today was his day on the phones).  

John said he could connect me to the consumer services hotline.  I told him I’d expect to have a long wait to speak to anyone at the consumer hotline.  He assured me that wasn’t the case, that they picked up right away.  He then connected me to the number I was planning to call today, foolishly thinking it was the NYS Insurance Department, 800-342-3736.

It will not surprise you, dear reader,  to learn that I found myself instantly back in a nightmare cul-de-sac.  This was the 800 version of the very first number I’d called yesterday, 212-480-6400.  I recognized the voice prompt tree: abandoned “zombie” properties — press one, mortgages– press 2, something else was three and “all others”, like those defrauded by a private medical insurance company they are forced to buy services from, press 4.

I pressed four and learned that the expected waiting time to speak to the same office I’d talked to the day before, on my first of six calls, was fifteen minutes. I called John Marconi back, but he’d called from a blocked number and the call could not be completed.

In the interest of completeness I dialed the final number I’d been given, for The New York State Department of Health, Division of Health Insurance, 800-343-9000.  A female robot greeted me:

“Thank you for calling E-Med Meade provider services.  This call may be monitored or recorded for quality purposes.   Please have your NPI number available.  

“For claims, billing, remittance form orders and prior approval questions, press option one.  For new enrollment into the NYS Medicaid program, revalidation… blah blah… and provider maintenance, press option two.  For explanation of eligibility response, press option three.  For MOAZ and threshold override applications press option four.   For Peatzar support, press option 5.”

It had taken less than three hours of my life to come full circle in the cycle of futility that is our current United States of voracious, psychopathic corporations and their human personifications.  

Our current president-elect is making good on all the business stimulating promises of the recent past: complete opacity, secret presidential kill lists, elimination of all health and safety regulations, denial of decades of science on the destructiveness of carbon released from burning fossil fuel, destruction of collective bargaining for workers, dismantling of the social safety net, nominating the CEO of the most lucrative private corporation in history, one devoted to extracting and exploiting every last bit of the fossil-based product that is doing the most to destroy life on the planet,  to negotiate on our behalf, etc.  

Let’s be honest, though.   He got a good start in all this from his celebrity all-star predecessor, that brilliant, caring, charismatic soon to be self-made billionaire, who is taking his subdued victory lap now prior to his sensational, highly engaging, funny, record-shattering “Raking in the Tubmans Tour.”  

God bless us all.

 

Protection from Fraud under the Patient Protection and Affordable Care Act

The short answer: there is none.

The longer answer:  

The NYS Department of Financial Services, any health insurance consumer’s logical first stop for answers about Health Insurance Fraud, had a longer than expected hold time (16 minutes).  There was nobody available at their fraud office today, they took my contact information and promised me an eventual call back.  They also have an online complaint form that you can fill out and, presumably, print, fold and insert into a body part exempt from your health insurance coverage.  

The kind woman I spoke to there, Norma, did not know of any place except the U.S Department of Health and Human Services that possibly oversees any aspect of the Patient Protection and Affordable Care Act.  Twenty-nine minutes after I’d placed the call  to her I was dialing 877-696-6775.

There was no wait at the federal agency, though also no option to speak to a human.  The voice prompts were limited, it seemed the best bet was being connected to my state Department of Health and Human Services.   I tapped in the requested information and was connected to the New York State agency.    

Unfortunately, it was the New York State agency that handles temporary or disability assistance.  I could press various numbers to get information about child support and other programs, but none related to health insurance.  

I eventually tried the administrative office options and spoke to a sympathetic woman at the office of legal affairs.  While her sympathy was solid, she did not have unlimited patience or time, and after five or ten minutes commiserating she connected me, without further ado, to the Fraud Hotline.  This number is 877-873-7283.

Sadly for me, it was the Medicaid Fraud Hotline, and as my program is not administered by Medicaid, I had to make a human appeal to an even more sympathetic woman, who, after twenty minutes or so, worked with her supervisors during a short twelve-minute hold, and was able to  give me two more promising, and seemingly self-evidently logical, numbers to call.  

One is the NYS Department of Health, Office of Health Insurance, apparently an unlisted secret number: 800-343-9000.  I surmise that it’s an unlisted help line because it took several long calls, ninety minutes of sleuth work today alone, and almost cat-like patience on my part, to have a supervisor at the Medicaid Fraud office think of searching for this particular number.  

She told me the number used to be on-line but they removed it from the website, presumably too much traffic on that line, too many strangled, inarticulate cries for help, too much rage and despair for New York State’s limited allotment of representatives to handle.

The other number is the New York State Insurance Department, which, while seemingly a logical number to give to someone with a complaint about insurance in New York State, is apparently equally obscure.  This office can, hopefully, be reached at 800-342-3736.

I don’t know why, but barely two hours into the calls now, I suddenly ran out of steam to tell my story to another person who agrees that there ought to be an ombudsperson or help-line to oversee problems with a federal health law administered by the states, particularly one that consumers are mandated to buy on pain of a tax penalty for refusing to participate in.  

Even though health insurance and pharmaceutical companies wrote the PPACA, and their liberal one-sided exemptions therefrom, even as the despicably corrupt right wing Democrat Max Baucus (recipient of millions in contributions from those lobbies — the fucking scion is now Ambassador to China– a little ‘thank you’ from smiling Obama) oversaw the process, even as health insurance/pharma industry lifer Liz Fowler wrote the law, you would think there’d be some oversight involved somewhere.  

You would apparently be wrong to think that.  Nowhere in the 2,700 pages is there any provision for a mechanism to protect patients from fraudulent denial of services under their one-sided contracts with the private corporations.

The last well-meaning woman I spoke to suggested I call Empire Blue Crucifix and talk to their internal complaint department about my accusations of fraud against them.  She assured me there had to be a number on the back of my insurance card for complaints.  I checked.  There was not.  I read her the options.  “Customer Service!” she announced hopefully.  I gently dashed her hopes.

Maybe I am thinking about the condolence call we are going to be making in less than an hour for Sekhnet’s old friend whose mother died the other day and I want to clear my head.  Or something like that.  I certainly do want to clear my head, I can tell you for sure.

And the minute the talented Mr. Obama is a former president, make like Robert De Niro wanted to do with Trump, which he can’t do now, obviously, because of Secret Service Agents and the private security contractor army that surround the new most powerful and important man in the world.

May I Vent a Bit Here, Mr. Obamacare?

I’m having a stressful day so far, as I wait for President-Elect Fuckhead’s latest publicity stunt to hit the wires.  I can’t keep it to myself.  Poor Sekhnet was bawling uncontrollably just now at my frustration before I could calm her enough to let her off the phone.   I need to vent, so if you’re not up for it, I understand, click away, click very away.

I went to an accountant who made a few minor errors on my taxes.  The first would have cost me almost $300, the second a little less than $500 in tax liability I apparently didn’t have.   I don’t hold this against her, going forward it won’t happen again, and, fortunately, I avoided both of those costs, as far as I know.   She told me to wait for the IRS to bill me on another matter, and I waited, and they billed me.

I paid this bill to the IRS.   Then two weeks later I received two certified letters from the IRS, threatening me with a levy or garnishment to satisfy the debt to them they claimed I hadn’t paid.  Their threatening certified letters were dated 12/12/16.  The payments to them were made on 12/5/16, confirmed on date of posting and the backs of both cancelled checks.   I wonder what their next letter will say.

But that’s nothing to get upset about, it’s easily resolved.  Just print out the images of checks, front and back, put stamps on their fucking IRS mailer and enclose the proof of payment with their certified mailed notice that they will begin collection efforts against me for a debt already paid.  Or better still, just wait for their next letter.

What I’m upset about is the Obama news conference I made the mistake of listening to just now, in the context of my ongoing horrors with his signature program, Obamacare.  

It’s true he’s killing people with drone-launched missiles in at least seven countries, off of a secret kill list.  Many of these people might be terrorists, no doubt, and hopefully few are innocent children and old women, or innocent men, for that matter.  His successor will have the same top-secret kill-lists presented to him for his approval.  

It’s also true that Obama has reserved, for himself and any future president, the right to kill American citizens without the need for any sort of process at all, with or without charges.   Tidying up afterwards is just book-keeping, most Americans are not paying attention, seriously.   Just pose with Kanye West or Kim Kardashian until the news cycle is over, done.    

I have plenty of beefs with Obama, who I voted for twice, but let me just give you the details of one I know better, and more personally, than anybody else I know.  Most people I know are comfortably middle class and work jobs where their health insurance is not at the mercy of the industry-written compromise called the Patient Protection and Affordable Care Act.  

You are assigned a level of health insurance based on your income as reported on your tax return.  If you don’t file tax, no Obamacare.  Fine, fair enough– the State Health Insurance Marketplace automatically gets all your proof of income statements anyway.  Submit your income numbers, get the level of insurance coverage your income entitles you to.  Choose any participating company to provide your care, at the assigned level, and start paying your premiums.  

I had a diagnosis of a slightly dilated left atrium over the summer.  The left atrium is one of the four chambers of the heart.  I asked my doctor how serious this was and he pantomimed a strong man pose, the healthy atrium muscle flexing, and then a limp armed pose, the same atrium, only flabby and weak.  He promised to refer me to a cardiologist, one who was joining his practice any day.  That was in August.

In September I began having pains in my chest when I did a strenuous bike ride.   I discontinued riding and kept following up to find out about the cardiology referral.  By November 17th I still had no referral and the doctor, returning my late night call about chest pains, agreed it might be best if I went to the E.R. to rule out a possible heart attack.  

Reclining on a bed in the Emergency Room, I learned the medical jargon meaning of “a good story”.  My EKGs had come back fine, my blood work was clear of markers for recent heart events, but as I was taking medication for hypertension, high cholesterol, and was 60– I had three of the five major risk factors and was, thus, “a good story.”  

I smiled, relieved, ready to go home, until the doctor explained that a “good story” was a bad thing, not a good thing.  I was a good story for possible heart disease and they’d better admit me to the hospital to rule out some deadly event that might soon befall me.

More out of shape than I’ve ever been, since I’d done no aerobic exercise in a few months since the chest pains while biking, I did OK on the stress test and was given a clean bill of heart health, cleared for all activities, though I was also diagnosed with an abnormality in one of my ventricles as well.

After payment for my visit to a neprhologist was denied as out-of-network since I had not pre-submitted the referred doctor’s location-specific NPI number and made sure he was in my plan at that location, I called Empire Blue Crucifix to make sure the next specialist I saw was in network.  

Empire gave me the name of a cardiologist and his office address.   I took pains to read back the site-specific NPI number for the provider and send his office the front and back of my insurance card.   I verified the doctor’s NPI number and was told by Maria at his office that we were good to go.   Ten minutes into my interview with the cardiologist’s assistant she was called away.  It annoyed me that she left the room mid-sentence, cutting me off without saying so much as “excuse me”.  

That annoyance would turn out to be a rather trivial.  Ten minutes later I was called back out of the consult room to the front desk.   The cardiologist himself was sitting at reception, very apologetic. He literally couldn’t have been nicer.  He told me that unfortunately the insurance company had informed his office that he was out-of-network.  We spoke for a few minutes, and I thought this was a person I could be good friends with, if circumstances were different.

I mentioned the importance of restraint as a musician and he raised his eyebrows.  “I should write that down: ‘restraint’…” he said, and we went on to talk about a master of that subtle and indispensable art, George Harrison.   The doctor gave me a print-out of all the materials from the hospital visit, with the intimate details and scientific names for my two or three heart irregularities.  We shook hands.  

My right hand, which has regained much of its strength six months after I injured it in a fall, is still stiff.  The P/T I began in November made it feel immediately better.  When I returned for my second appointment I was told that, unfortunately, I was out of network.  

I got a referral from my insurance company, complete with site-specific NPI provider number, for another P/T provider two blocks from the cardiologist.  I walked over with my referral form after my aborted visit to the cardiologist to set up an appointment to resume P/T.

I was surprised that I’d walked into what looked like an Old Age Home.  I checked the address, I was in the right place.   The receptionist was surprised that I was there for outpatient P/T.  She wasn’t aware they offered that.   The director, over the phone, told me they did offer P/T, but only if I checked into the nursing home as an inpatient.

I walked home 0 for 2 on referrals given to me by my insurance company.  I thought of the third notice of a $1,324 medical bill I’d received the day before for a sonogram I’d had months earlier.  I’d had an x-ray of my hand and two sonograms that day.  The x-ray and one sonogram were both covered, the other was not.  $1,324, please.

 After the second notice demanding $1,324 I straightened things out, on October 19th, with the insurance company and the provider, it took less than an hour.  Daniel at the provider told me I’d been billed in error and actually only owed a $25 co-pay.  I told him I’d pay it when they billed me.  Then, six weeks later, I got the third notice to pay $1,324.    

This time, I was told by the insurance company, that I was responsible to have read all of the fine print in my contract and that it was clearly spelled out which body parts were not eligible for coverage.  She was not able to explain the reason for this, but assured me it was the law, all described clearly in the contract.  She then called the provider and confirmed that I owed the entire $1,324.  Daniel had no recollection of having spoken to me, on October 19th or any other day, she said.  

It was a purely futile conversation and there was no supervisor available for me to whine to.  Empire’s position was that it was my responsibility to familiarize myself with the arbitrary and random bodily exclusions from coverage under the specific policy I had under the newly-created Essential Plan.

Tired of making Sekhnet cry, I thought outside the box just now and had a very pleasant twenty-five minute chat with a thoughtful and intelligent man named David at 311, the NYC information hotline.  

David had only one number for complaints about medical insurance, the New York State Department of Financial Services, naturally.   You can reach them Monday to Friday from nine to five at 212-480-6400.   He doesn’t know if they investigate medical insurance fraud, or oversee any agency responsible for assigning and administering health care in New York State, but it was the only thing he could find, though he searched long and hard.   He recommended I contact a local politician for help, they usually know how to do these kinds of things.

He agreed that the new norm of corporate opacity in government is very troubling.  I told him how the New York State Health Marketplace would not divulge contact information for its director, when I was erroneously denied health insurance for two months earlier this year and called many times trying to get the error corrected and have my health insurance reinstated.  

“Sir, we are not required to provide you that information,” one of the New York State of Health representatives told me from their call center in Albany.  

“Why is that?  Are you a private corporation?” I asked.  

She admitted that they are a public agency, but reiterated that  a member of the public is not entitled to know the identity of the director. They have specific instructions not to provide their boss’s contact information.  Their supervisor will not provide that information either, nobody will.   As for an ombudsperson, or someone available to help distressed customers, they are not required to have one under the Patient Protection and Affordable Care Act.  

They have an appeals process for all disputes.  I initiated an appeal and was told I’d hear within two weeks.  I heard nothing, nobody could give me an explanation for the delay.  Two months later my health insurance was back in effect and I began paying my premiums.

Two months after that I had a call from an appeals ‘hearing officer’.  He asked me if I was ready for my appeal over the phone.  I asked him why I’d received no notice of the hearing.  He told me a notice had been sent to me thirty days earlier. He directed me to where I could find it on line.  

There was no notice there.  He saw it on his end, he told me.  I pointed out that if the person who is entitled to notice doesn’t receive any notice it really doesn’t matter if a form was prepared or not.  

He was not the sharpest knife in the drawer, and had a shit job, no doubt,  but he was on point, I’ll say that for him.  No matter what I said he returned to his single question: are you prepared to go forward with your appeal or do you wish to abandon your appeal?

I explained, in vain, as it turned out, that since I had been appealing a denial of benefits for January and February, and it was now May, that we would need a time machine in order to have a meaningful appeal of the wrong I had appealed.  

“Do you want to abandon your appeal or go forward, you have to tell me one thing or the other, sir,” he said.  

I went out on a limb and used a word many people mis-correct as “mute”.  I told him it was academic, since the controversy was now moot — the harm was done and could not be corrected any more due to the passage of time.  He asked his single question again.   I explained the concept of mootness to him.  I might have been explaining it to my own sonogram-exempt body part.

Obama was surrounded by organized, determined, ruthless enemies, no doubt.  He had very wealthy donors in the industry that, in fairness, he had to consider as well as the public his law was designed to protect.   However you slice it, Barack Obama is the Obama of Obamacare, and I hope he will not be too offended if I point out again that he’s a sell-out and a bit of a dick.

One reason Trump is President-elect, why most Americans hate their government, and why they hate others, as well

I voted for Barack Obama twice, holding my nose the second time. “All presidents disappoint”, Bill Moyers reminded his viewers during the euphoria (for many) when Obama was elected the first time.  Moyers’ reminder was one of the most sobering, and prophetic, I can recall.  Obama, smooth, thoughtful, droll, sensitive, has disappointed more than any other president in my lifetime.  

For but one example of my disappointment, let’s have a peek at his signature achievement, The Patient Protection and Affordable Care Act, popularly known as Obamacare, the program the president-elect has vowed to repeal as soon as he’s inaugurated.  

I am the only person I know who is directly affected by the outgoing president’s masterful compromise with the massive health care corporations who need to remain as lucrative as ever.    I speak of the workings of the PPACA with bitter personal familiarity unmixed with statistical satisfaction of any kind about things like the possible long-term altering of medical care cost vectors.  

The law was a hasty compromise with what was sorely needed to prevent tens of thousands of preventable American deaths every year.  It was written, by industry insiders, to ensure, above all else, that the private insurance and drug industries would remain as healthily profitable as possible.  

Written by wealthy health industry lifer Elizabeth Fowler (check out the great five minute Bill Moyers clip at the bottom of the link) who worked, during a brief sabbatical in ‘public service’, for the most handsomely paid (by the Health Insurance and Pharmaceutical industries) man in government, Montana Senator Max Fucking Baucus.  

Baucus apparently admitted never having read the bill, stating that it would have been a “waste of time” to do so, because only an expert could understand its 2,700 pages (NOTE: the author of the linked Washington Post article, no friend of Mr. Obama’s, is a professor at the ‘Antonin Scalia Law School’ whatever the devil that infernal place is).   A somewhat less biased account of Baucus, with a passing note on his ambivalent role in the crafting and passage of the PPACA, is here.

One learns from the Grey Lady article that Baucus is the scion of a “prominent and mostly Republican” Montana ranching dynasty who always “marched to his own drummer” as he did, one assumes, when accepting Obama’s appointment as ambassador to China rather than face sure defeat in a re-election bid as Montana Senator after three and half decades on the job.  

Baucus took over the lead role shepherding through the PPACA when Ted Kennedy died.  Baucus is known (albeit not well) for these right-wing, business-pleasing votes, as well as for taking millions in campaign contributions from concerned health industry lobbyists:

In 2001 Mr. Baucus defied Tom Daschle, then the Senate Democratic leader, by co-writing President George W. Bush’s tax cuts, setting off screaming matches between the two Democrats. In 2003, Mr. Baucus broke ranks to support a Medicare prescription drug benefit that Democrats viewed as a giveaway to drug companies.  (source)

You can google either of these characters, Baucus or Fowler, to read their sordid bios.  One can admire the way Ms. Fowler danced through the revolving doors, and made millions while serving her fellow health industry executives, without applauding, or even cracking a smile about, the sickening health care law she lovingly crafted for Mr. Obama’s signature.

Anyway, I’m just worked up because I got “an important notice” from the New York State of Health in the wee hours of the morning. It arrived at 3 a.m., certainly the most effective hour to send such crucial health insurance-related news that likely impacts a patient’s immediate health insurance coverage.  It read: 

A notice has been sent to your inbox in your account. This notice tells you important information you need to know about your health coverage for you and/or your family.

You must log into your account on the NY State of Health website to read the notice.

The careless motherfuckers at New York’s Obamacare “marketplace”, The New York State of Health, contacted me last year, with an almost Josef Goebbels-like sense of mischief, on Christmas Eve and Christmas Day to inform me I would be ineligible for health insurance until March 1, 2016, at the earliest, and gave me seven (7) days to provide all tax forms and a full, written explanation of why I should be given health insurance at all.

 

Almost lost in my inbox, I took a moment just now to log into the accursed site and read this:

Screen shot 2016-12-04 at 3.04.34 PM.png

IMPORTANT NOTICE:   Today is December 4th, please come back AFTER December 15th to keep your insurance up-to-date and in place for 2017.  On, or just after, December 15th you will then have up to 24 hours — provided our servers, often overloaded just before our short, arbitrary registration deadlines, do not crash– to provide all required updates within that short window in those leisurely days before Christmas, or lose your insurance coverage until, the earliest, March 1, 2017.  

Or maybe not.  Nobody you speak to at New York State of Health, after a wait of no more than 25 minutes, will have the definitive word on what’s what.  The only thing you can rely on regarding the New York State of Health is not getting reliable information.  Take heed, though, and take that to the bank, bitch.

I’ll be eagerly following Barack Obama’s career as a private sector public speaker.  I am confident that my man will break all existing earning records for corporate speaking.  He’s that good.

The Patient Protection and Affordable Care Act

The New York Health Exchange, which determines the metallically designated (platinum, gold, silver, bronze)  level of PPACA insurance coverage your income qualifies you to have, has no ombudsperson.   It has no meaningful appeals process to correct things like an error that deprives a patient of health coverage for a few months.   The name of the director of the New York State of Health, if you ask, figuring you will contact that office directly, is none of the public’s business, although the enterprise is a wholly public one.  

It employs practices that fit the definition of “arbitrary and capricious” but would probably not be so deemed in a court of law.   You can hire a lawyer to bring an Article 78 proceeding, under NY State law, if you have a few thousand dollars lying around, but, there is zero chance of recovering any kind of monetary damages, so why go there?    

The Patient Protection and Affordable Care Act could, as accurately, have been called the Health Insurance and Pharmaceutical Industry Profits Preservation Act, but while the name would have been more truthful, it would have been a harder, and more embarrassing sell for the president.

But, let’s leave all that aside for now.    

Now you have health insurance assigned to you and you pay your premium. You liked the doctors you’ve been seeing for years, and were promised you could keep them, but that was not a truthful promise by the president.  No problem, and don’t get all pissy about it.  You find new doctors and you can have medical records sent to them for free by your old doctors, provided you send the proper authorizations to each previous doctor’s office.  Not really much of a problem, as anyone would agree.  

Except when you try to find out who will pay the new doctors for their services.  Then it becomes the patient’s sole responsibility– and you’d better be smart and patient as hell, preferably a trained lawyer, too — to figure out what you have to do so that you won’t be left holding the often shockingly unaffordable bill.

Although there is no requirement in the law that the patient be informed of the price of any medical service until after it is rendered (and therefore, purchased) it turns out to be possible, if not simple or straightforward, to research which services and providers are covered by insurance under the Patient Protection and Affordable Care Act.  

All you need, in the end, is the provider’s NPI number.   You call the provider (in health insurance jargon doctors and hospitals are called ‘providers’) request and write down the ten digit NPI number for that provider. Then you call your insurance company where you can usually speak to a representative within less than twenty minutes, since they are generally busy assisting other “customers”.   You give the person who answers the NPI number and then go back on hold while they connect you to someone who knows what an NPI number is.  

Do not get overwrought when the ads you are listening to while on hold are suddenly in Spanish, or in Mandarin.  You can never be sure, from a marketing point of view, which language ad will be the most ‘impactful’ even if the customer did not oprime el numero dos when given the choice of languages.  It is best to remain free of judgment while on hold.  

One must not be unduly disturbed by the thought that every health-related transaction is driven by the imperative to maximize corporate profit.  It is also important to keep in mind that any aggravation you may experience while on a long hold has nothing to do with any active desire to make things harder for patients trying to get medical treatment.  The health insurance company keeping you on hold to speak to customer service is only trying to keep costs down, for your ultimate benefit.  

“You didn’t get the provider’s NPI number?” the representative may say, throwing up her hands.  If you had the foresight, and got the NPI number, it is only a minute’s work for the insurance company representative to look up the doctor, determine if the provider is “in network”.  If you have not made a prior call to the provider to learn the provider’s NPI number you create additional work for a representative who does not get paid very much to do the patients’ work for them.  

You may learn, to your great surprise, and only 51 minutes into your customer service experience, that one provider may have multiple NPI numbers, each corresponding to a specific office location and associated telephone number.   Call the wrong office, or even the right one picked up at the wrong location, and the NPI number and provider are no longer “in network”– even though it’s the same provider, it’s a totally different NPI number, which should be obvious enough.  

From the insurer’s point of view, why would you expect to have insurance pay for a provider who you think is in network, even if the insurer itself told you so, if you do not have the correct NPI number for the specific service delivery situs you are making an appointment to see that provider at?

I understand that the bottom line in our global economy is corporate profit.  I get that, I really do.  I don’t like it, particularly when applied to health care, but I understand we live in a materialistic world and that corporations are legally constructed psychopaths the Supreme Court has us pretend are living human beings for purposes of their right to have a say in the government that makes and enforces the laws they must “live” by.  I get all that, I do.  

I get that all presidential candidates lie, that all presidents disappoint, that Mr. Obama was no worse than most in either of those areas.  He was better than some recent ones, certainly.  If you’re going to be fleeced by a predatory corporation, or killed by a drone without charges or trial, or have your phone and email records secretly collected, or be denied a Freedom of Information request, or threatened with the death penalty for being a diligent journalist, or anything else Mr. Obama or any other American president might do, you might as well get that treatment from someone who is thoughtful, funny, smooth, cool, calm, who knows how to sound like his heart is always in the right place.

I don’t begrudge B.O. the hundred million in speaking fees he will get in the next couple of years.  He’s brilliant and very talented and deserves the handsome fees much more than most of the famous and infamous speakers who get paid obscene sums to inspire corporate audiences.  God bless America and God bless his freedom to make those hundred million in the next few years.  Couldn’t happen to a nicer guy, as far as I can tell.

That said, I have limited patience for statistics-spouting, blindly partisan defenders of a deeply flawed,  perhaps fatally compromised, solution to a long-standing problem that afflicts millions of our most vulnerable, especially if that partisan defender has had no personal experience with the day to day niceties of the Patient Protection and Affordable Care Act.  

The outgoing president, taking his bows now in a last well-measured victory lap, has to get some of the blame for the many flaws of the monstrously complex, profit-driven health industry-favoring law that bears his name.  

You want to point out that he’s been surrounded from day one by detractors, many of them racists, snarling, unreasonable, petulant obstructionists who have done nothing to fix the flaws in the complicated, problematic law, outside of trying to repeal it countless times?  Fair enough. But the solution the president put on the table at the start of negotiations was designed, before anything else, to ensure that health insurance and pharmaceutical company profits were kept as healthy as possible.    It was drafted, after all, by experts who went back to work for those industries after the bill became law. 

And, as in any zero sum game, the weaker party, regrettably, wound up, inadvertently and completely unintentionally — and we’ll stipulate, out of respect, that it was done with only the best of intentions — burdened, scammed, coerced, unaffordably billed and, in many cases, simply fucked.  

But, hey, would you rather have a preexisting condition?   Or die in an E.R. with the 45,000 other Americans who died every year for lack of health insurance?   Thanks to Obamacare the number of Americans who die in Emergency Rooms for lack of decent preventive health care is certainly much lower now.   Though statistics are hard to find, I’d wager that terrible number has been cut in half.

As the president said when signing the flawed law “don’t let the perfect be the enemy of the good.”  Or, as a patient protected by the PPACA might say, “don’t let the good be the enemy of the fairly crappy.” 

LOG INTO THE NY STATE OF HEALTH WEBSITE TO SEE IMPORTANT INFORMATION ABOUT YOUR HEALTH COVERAGE

Two Christmas Day emails from the tireless Obamacare spambots after months without a peep from my ruthless benefactors.

Happy Christmas, sucker, (click the link to see, inter alia, the letter informing you that your health care insurance has been canceled, effective immediately, for unspecified reasons.) 

On the website, the message is a bit cheerier:

Congratulations

The email arrives, arrives again, reminding you there is a message in your INBOX.  It could be anything, it arrives on Christmas Day, should be some good news.

 

LOGIN to Obama's asshole

Have a nice day.  You have ten days to produce all required (if any) documentation at our Albany offices before this decision becomes final and binding.

Obamacare website

 

Don’t Take It Personally, Man

You may be correct to feel that not being told the price of a medical service until after you’ve bought it is like going into a store and not being told, until after you make the purchase, the nonrefundable price, which you are 100% responsible to pay.   Or, like a restaurant where the bill is secret until after you’ve eaten, a policemen waiting to take you in if you refuse to pay whatever the restaurant demands.  Seems unreasonable, un-American, but according to the Patient Protection and Affordable Care Act, the practice is neither of these when it comes to medical services. 

Critics will be critics, and some critics ignore the facts in their zeal to score points, but a few things about the flawed step forward that is Obamacare (The Patient Protection and Affordable Care Act– PPACA) are beyond dispute. Systemically, it is an improvement over what existed before.   The elimination of the grotesque loophole of “pre-existing condition” exclusion from coverage alone was worth the fight.  Giving the medical industry financial incentives to prevent disease rather than continuing to profit off billions in late in the game testing and end of life treatment is another long overdue step in the right direction.  It can’t be denied that millions more Americans have health insurance under the PPACA and access to preventive care, many for free.

 Those things said, huge problems remain with this compromise, authored by a health insurance industry insider,  that keeps the private health insurance and pharmaceutical industries firmly in charge of seeing their profits undisturbed.    Millions are still uninsured under the PPACA and tens of thousands of Americans will continue to die preventable deaths every year from treatable diseases discovered only in their fatal stages at ERs across the country.  

 Individuals may find also find themselves among a few million in an income category a little too high for free service, and too low to qualify for and afford the premium service members of Congress receive.  Such persons will, unfortunately, be a bit screwed by the details of the PPACA.  

The high deductibles, outsize charges for routine services, billing irregularities and other unappealable indignities may cause these patients to feel unprotected and that the mandated health care they pay for each month is sometimes obscenely unaffordable.   These Americans must take solace from the fact that it is truly nothing personal.

 Yes, it’s your individual problem, true, since the bills will be enforced by lawyers sent to collect all charges, but take courage in knowing that you are not alone in being partially unprotected by the Patient Protection and Affordable Care Act, an otherwise wonderful program.  It’s nothing truly personal, surely you can see this.  It affects millions, so stop your belly-aching!

 If you consult for twenty minutes with a physician’s assistant, for example, who has never heard of the symptom you report, repeats your google research while you sit there, and who orders a blood test to rule out certain things, you may have a little sticker shock when you get the bill for $507.   This sticker shock comes about because there is apparently no provision in the law that the patient be informed of cost prior to receiving a service.  Call your insurance company and they will tell you the doctor must first bill them for the service and then the price is determined, according to negotiated rates, and sent back to the doctor, who will in turn bill the patient the deductible amount.  

It’s all right there on the bill:  consult with physician’s assistant:  patient’s responsibility– $180.   Subsequently reduced, without explanation, on a follow-up bill thirty days later, to $110.   Blood test:  $641.  Patient’s responsibility:  $327.   Insurance, oddly, paid the corporation representing the doctor $314 for the blood test.   $437 for a visit to a physician’s assistant?   Call to ask about these charges and you will be told the charges are all correct, sir, all the proper codes were entered, these are the legal rates your insurance company agreed you would pay.   You can take it up with the attorneys who are handling the collection matter for the doctor’s office.  

 Have a nice day and, please, keep in mind that this is strictly legal, enforceable and absolutely NOTHING PERSONAL!   Only a baby would take it personally, though plenty of folks, apparently, are squawking like babies about their treatment under this inarguably great step forward. 

 To be fair, though, would you rather be treated unfairly with the right to be hospitalized (at no expense beyond your premiums and deductibles) when you finally have a stroke or without that right?  You’d have to be a fool not to see that this is a no brainer.