Or should I say, “Obama, care for me.” What a fucking nightmare health insurance can be in this country. When it works, it can be great, it can be basically flawless. 8 years ago, when I was diagnosed with aortic aneurysm and needed to schedule a surgery relatively quickly, it was all handled by the various doctor’s offices and hospitals without my having to do anything. The result was that my open-heart procedure, performed by one of the leading surgeons in the country and followed by a week at Stanford Medical Center, cost me a total of $10. No questions, no headaches, no massive medical bills that I needed to challenge. I simply received an invoice from my provider at the time, HealthNet, stating that they had paid $280,000. and I owed nothing, having already paid Stanford my $10. co-pay.
Fast-forward to today. I’m now covered by Aetna, and have been for the past 3 years. However, every year when I renew through my employer’s health insurance program, there seem to have been changes implemented since the last time. This year, apparently, the “medical group” which provides my “health care providers” and therefore my treatment has changed.
Last week I was to see my cardiologist, for my annual echocardiogram and follow-up consultation. The day before my appointment – one day before – her office called me to say that they’d just noticed that my insurance had changed, and that they did not accept insurance through my new medical group, Hills Physicians. In the past, this kind of situation has always been easily resolved by getting a referral from my Primary Care Physician, so I rescheduled my cardiologist appointment, and put in a request for this referral with my PCP.
In fact, I had needed a different referral just a couple of months ago, when a sudden hearing problem necessitated a visit to an ENT specialist. That referral proved to be no problem, and I have since seen the ENT 5 times. However, he was not able to get to the root cause of my problem, so wanted me to see a rheumatologist. This of course necessitated another referral, from the ENT to the rheumatologist.
So as the calendar ticks down on the last few weeks of 2013, I have been trying to schedule appointments with both of these specialists, and get the necessary referrals, which require literally hours of phone calls – much of that time spent wading through phone trees, then leaving messages because the humans are never actually available to speak with, and then repeating this process a week or so later when they have left a message on my phone.
Today I was to see the rheumatologist. I’d made the appointment a couple of weeks ago, and my ENT’s office had assured me that the referral was in place. But this morning – yes, about 6 hours before the appointment – I received a voicemail from their office. The “new patient coordinator,” with whom I have spent seemingly hours not talking, had called to tell me that the “authorization” that I needed had not been received…
An authorization is not the same thing as a referral. An authorization is required from the insurance company for payment before a procedure, e.g. a CT scan or an MRI, is performed. A referral is when one doctor sends the patient to another doctor. The referring doctor would initially be the PCP, but after that it can be a daisy-chain. In my case, the ENT to whom I’d been referred by my PCP was now referring me to a rheumatologist. Only apparently he hadn’t.
More phone calls, to the rheumatologists office (I left at least 3 messages there today; she has never answered her phone over the weeks that I have been calling), to the ENT’s office, and also to Aetna.
Surprise, surprise, Aetna proved to be the most helpful of all. Not only was I quickly talking to an actual human being, having dialed their customer service number, but she was unfailingly polite. When I described the problem, that the rheumatologist had not received an authorization, she put me on hold while checking the status of any pending requests. When she returned, she asked if it was not a cardiology authorization that was needed? Because that was the most recent one they had on record, and in fact it had just yesterday been denied.
Cardiology authorization? Denied?! Okay, well that’s a separate piece of bad news. We’ll have to deal with that later. (This was an authorization because a procedure – the echocardiogram – was involved.) But what about the rheumatology authorization/referral? It was at this point that the Aetna rep explained to me the difference between an authorization and a referral. And when I told her that the referral was coming not from my PCP but from my ENT, she even went on to call my ENT’s office to inquire. But the person who handles the referrals was unavailable…
I of course had to cancel my appointment with the rheumatologist – for which I most certainly had better not incur a penalty, something many doctor’s offices do, for a cancellation within 24 hours of a scheduled appointment – and request another for next week, all by means of voicemail of course, since I still could not reach the human.
Later, a voicemail came from my ENT’s assistant, saying that she had indeed made the referral to the rheumatologist, and could document that… prompting me to leave yet another voicemail at the rheumatologist’s office, which I hope was not too shitty in tone, just a little shitty, asking her to please figure out what was going on, and leaving her the contact name and number at the ENT’s office.
Maybe, before the end of the year, I will see a doctor…