Wednesday, November 17, 2021

Get a Health Insurance Plan That Doesn't Require Referrals

In 2021, my health insurance (Empire Blue Cross/Blue Shield/Blue Man Group/Kinda Blue) started denying my claims, including procedures they’d pre-approved. After hours and hours and hours on the phone with their reps, I finally wound up paying a bunch of bills out of pocket, and my credit rating is now something like "high-functioning wino".

Finally, I befriended a sympathetic claims supervisor, who explained what's happening via euphemism and code (because my call was Recorded For Training Purposes):

It’s a combination of “Never ascribe to malice that which is adequately explained by incompetence” and...well, malice. The claims people are all working at home since COVID. Not sure they’ll ever go back. And the chain of referral (between insurer and doctors) mostly runs via fax machine, and the fax machine is, naturally, at the office. Yup, it's that stoopid.

Even fax aside, there was a PROCEDURE to handle referrals and the procedure breaks with work-at-home claims people, and it hasn’t been a priority to fix (which I attribute to malice). So when clerks processing claims don’t see the appropriate referral right before their beady little eyes (and they often don’t because the procedure’s broken), they blithely deny, and blame the patient. Easy/peasy!

This checks out. My GP always got paid, but specialists and procedures seldom did. Even when I had immaculately provable proof (fax receipts from docs, preapprovals, etc).

In October I shook myself awake and realized what this really means: in the event of medical catastrophe, they might not pay, which meant I was effectively uninsured - a galling predicament considering the $$$ I pay every month. So I sucked up the loss of my year-to-date deductible tally, and switched carriers to MVP, an obscure upstate NY operation which I believe is an artisinal small dairy farm dabbling in health insurance (kidding). Slightly cheaper plan, way fewer doctors (which is awful), but no GP referrals necessary.

Post COVID confusion is not a good time for procedural complexity (a mantra to bear in mind in all one's dealings), so a referral-free plan is now way, way more important than ever. I strongly recommend sacrificing other desired features to get such a plan.

E.g. I have a stomach condition which remains untreated because the good gastros don’t take MVP and I didn’t trust BCBS to reimburse, and the helicopter has not appeared to deliver capable fixers who'll make everything okay. Welcome to healthcare 2021! Hey, at least I’m not intubated and gasping!).


Adam said...

Health insurance is a bad industry. Not many industries that can reliably get pols elected when they say it will be destroyed (even ATF can't do it). I like to point that out to every rep I speak with.

James Leff said...

ACA was supposed to fix these problems, but once again we see that you can’t outpace miscreants and kludge fast enough via regulation. Creative non-compliance is a more lucrative pursuit than meth.

Tom from Raleigh said...


Have you ever looked into medical tourism? You could go back to Portugal for treatment or one of many other countries for healthcare. I had a few procedures done in Portugal and was very happy with the level of care.

James Leff said...

That’s a smart idea! Mostly I’ve just been looking forward to Medicare, though I do have a while.

Hey, are you back yet? Did everything wrap up ok?

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