1/9/09 Insurance is Inept

Today I called my insurance company for the first time in order to confirm/ask for clarification on my benefits. I spent some time gathering information and preparing for this call online. Let’s just say I wish the insurance people were half as prepared. I really only had a few questions; 1) I wanted to confirm my policy hadn’t changed this year. 2) When exactly can I apply for approval, so what exactly is 6 months/diet (is it a certain no. of days? Is it 6 weigh-ins or 7? I’ve heard all these answers on the web.). 3) What will my costs be- deductable, percentages, maximums? And how are fills covered? 4) Do I need to remain above the minimum 35 BMI until approval?

Is it too much to ask for some clarification? In a world such as insurance where everything is supposed to be black and white, why is there so much gray? I play fair (OK, except the layers)…I get that they need minimum BMI’s and can’t just arbitrarily approve people…I won’t whine about the rules. I’m a girl; I don’t mind reading the directions, but, for example, what the heck is up with just listing examples of some comorbidities, etc., dot, dot, dot. Why not just list the specific list of ones that will gain you approval so you know if you should apply or not? Why do I have to decipher after many hours on the internet that only 5 of the obesity related comorbidities really count at all toward approval? If there are specific rules why the @%&* aren’t the rules to this ‘game’ spelled out clearly? It’s like trying to play a game that your kids made up and the rules just keep changing.

I was sweet as pie on the phone…we weren’t making any headway until I told the rep. that I had a copy of last year’s policy…OK, there we go #1 down…no changes. Then came the 6 mo. question and I explained it further. She put me on hold as she asked her supervisor. When she came back she told me it all depended on whether I’m outpatient or inpatient as different departments handle these. OK, I’m in, so WHAT DOES 6 MO. MEAN? I know you’re all screaming at me, better safe then sorry, just do the extra mo., but this is a major difference in BG-land. My kids are both graduating the next mo. so that will be dicey with ceremonies, company and parties. We skipped to costs and they were what I expected ($1000 max), but she had no idea what a fill even was. At that point she transferred me to the pre-authorization department. The rep. that answered was immediately p.o.’d when she found out I wasn’t a Drs. office and all she would tell me was my Dr. would fax the papers to them for approval…she couldn’t answer anything else. Frustration.

I took a deep breath (sigh) and decided not to sweat it as I have my surgeon’s consult next Tuesday. I’ll be meeting with the insurance expert from the surgeon’s office as well as the surgeon. She seemed to be very aware of my insurance co., so I’m hoping she has my answers.

OK, here’s my real rant…My last job being in business process improvement, this part burns me…I’m not mad at the rules, I’m mad that if there are rules, no one gave all of them to me and this is plain stupid. How can this not lead to more costs for insurance? I get that by being vague they might be able to deny a few more people at the end, but weigh that against all those who wouldn’t have ever embarked upon this process if they knew they didn’t meet the qualifications…how much money is lost on them? How many people go through months of PCP visits, pre-op visits with psych, NUT, etc. (how much does that cost?) only to get denied for something the insurance co. should have spelled out to begin with.

As difficult as diets have been for me in the past, it doesn’t begin to compare to this insurance maze. I just don’t get the game, or even more, why there’s even a game to begin with…and I’m just starting.