The rotten US health care system-part 3

As I wrote yesterday, my latest bone density scan, when compared with two previous scan results taken years before showed that my bone density was not only above the cut off for a diagnosis for osteoporosis but also was actually increasing with time, so there really was no cause for alarm.

Thus the diagnosis of osteoporosis that had resulted in the insurance company declining to cover the costs of the scan and the radiologist’s fees was obviously a mistake and you would think that it would be a simple matter to get it cleared up. All you would have to do is point out the obvious error (the doctor, the hospital, and the insurance companies had access to all my old medical records) and everything should be fine. But when I contacted the insurance company they said that in order to get the error corrected and the scan covered I had to get the hospital that did the scan to resubmit the claim to the insurance company with the correct diagnosis.

You would think that this also would be a simple thing. But when I called the hospital they said that I had to first contact my doctor and get them to submit a new form with the new diagnosis. When I called the doctor’s office, they said that they had concluded that I had osteoporosis based on the results of my previous scan results. But since I had my latest and old scan records and knew how to interpret the numbers and knew the difference between osteoporosis and osteopenia, I was able to point out that they were wrong. They conceded that I was right and that the error would be corrected.

So that’s that, right? You would expect that now everything would fall into place. You would be wrong. In fact, I predicted that I would still encounter problems in my efforts to correct this because of the bureaucratic nightmare that is the profit-seeking US health industry that benefits from denying care, and I was right. I still kept getting monthly bills for the scans and radiologist fees, and on checking the insurance company website and calling them found that nothing had been done by anyone. This resulted in a long round of phone calls by me to various people and finally in January of this year, eight months after the original scans and seven months after I brought the error to light, the matter was settled in my favor with the insurance company paying all the bills.

I will not bore you with all the details of what I had to do in order to correct what was an obvious mistake. In summary, I had to make 17 phone calls to the hospital’s billing office, 15 calls to my doctor’s office, 9 calls to the insurance company billing office, and 4 calls to the radiologist’s billing office. Each of the phone calls to the insurance company and the hospital billing office involved first going through those infuriating and long menu systems that require you to choose between options and provide all manner of information before you get to talk to a real person. The worst ones (especially for people like me who have non-native accents) are those that use voice recognition, though I must admit the software seems to have improved somewhat and I am not misunderstood nearly as much as in the early days of this technology. In addition, I had to visit the insurance company’s website numerous times to check on the status of my claim.

The sad fact is that I am sure my experience is not unusual. This kind of runaround is what many people experience in the US system and people in other countries would be horrified that we meekly put up with it. This kind of thing should not happen in a well-designed health care system like one has in single-payer programs and we should not put up with it! In my case, the experience was merely exasperating and time consuming. In the worst-case scenario I could afford to walk away from the aggravation by paying the two bills. Also my condition was not life-threatening. But for people who are dealing with serious health issues and also cannot afford to pay, the thought of being stuck with a large bill that they did not anticipate could be very stressful.

Note that I am also fortunate enough that I have the knowledge and access to information to understand the implications of the scan and lab results, to learn about what numerical codes should be assigned to various diagnoses, and also have the time and the ability (and persistence) to navigate through the complex system. Most people are not so lucky and they likely give up and pay the bill because they either get fed up or are overwhelmed and intimidated.

Next: Lessons to be learned in dealing with the system


  1. Scott says

    I really feel for you, Mano. Luckily, we haven’t had too many issue like that with our insurance (I’m on my wife’s, not Case’s). What I find odd is that if you’re getting your car worked on, you’re told ahead of time what’s wrong and what it will cost and if it’s covered under warranty. If you’re getting your body worked on, you have no clue whether or not it will be covered before you have something done.

  2. ollie says

    Practical tip: when the insurance company starts jerking you around, get your Human Resources department to deal with them. They have clout and lawyers.

    It shouldn’t be that way, and your point about our health care system stands.

  3. says

    Intesead of doing the health care reform they should invest in preventative care. It amazes me the number of people who can’t even walk one flight of stairs. Give more time off from companies if you go to the gym and work out would be a great incentive.

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