NAKED CITY Sick of This Mess

I AM THE INSURANCE MAVEN.

Every family has one. of course. I collect the medical bills. I fill out the insurance forms. 1 clip them together and send them off. And then I wait and wait, with a healthy dose of skepticism and foreboding, for the insurance company decree. It comes in an “explanation of benefits”-a litany of impenetrable insurance-speak (e.g. co-in-surance provider’s share; primary benefits) that always seems to boil down to: Eat your own medical expenses, pal.

Mine is an unrewarding job. It’s painstaking, laborious, demeaning (I’m always begging). It brings very little payback. I give Blue Cross & Blue Shield of Texas Inc., $2,196.12 a year-on top of the $4,694.40 my husband’s employers pay. In return, they’re supposed to pay our medical expenses, though it rarely works out that way. Not only am I helpless to do anything about it, but when I complain, they sort of chuckle at me on the phone.

But this is not about hating my insurance company-which [do, with a passion that grows in direct proportion to my premiums, which seem to rise as last as my benefits decline.

This is about the big picture-bigger than the fact that last year my newborn had seven routine checkups but Blue Cross only paid one. (Their policy is one checkup a year, they told me. though they’d have been happy to pay any sick bills that might have resulted from skipping those six uncovered checkups.)

No, this is about thinking, foolishly, that there’s a higher good somewhere in Insurance Land; that as long as I win my little battles-as long as I recoup a lost penny; resubmit a rejected claim; wait out the customer-service representative who has put me on hold while she goes to lunch-I will one day get my money’s worth. My premiums will top out, My bills will be paid without question. Helpful Blue Cross employees will answer my calls on the first ring. And the world will be fair and just.

But there are insurmountable forces working against me. 1 learned this at Baylor University Medical Center.



LAST DECEMBER. MY HUSBAND had the flu, And it wouldn’t go away.

After three weeks of headaches and fever, he lay in bed on a Saturday night, under an enormous pile of blankets, shaking and chattering and running a 104-degree temperature. I called his doctor, who immediately dispatched us to Baylor emergency We stayed there for the next eight days, while a team of doctors and specialists and residents took turns puzzling over my husband’s overheated body.

Fifty-three tests and 140 pills and injections later, they came up with the answer: flu. On New Year’s Day. it went away. But not before we spent another 10 days at home with my husband on an antibiotic that I administered, gingerly, through an IV. Whether all the tests and drugs were absolutely necessary. I can’t tell you. You either trust doctors, or you don’t. And we did. But one thing’s for sure: The bill was grossly excessive.

I learned this from my trusty “explanation of benefits” sheets, which began arriving in my mailbox at the rate of three or four a day. According to Blue Cross, the eight-day hospital stay had cost $7,003.08. The at-home drug therapy-an antibiotic, an IV pole, supplies like needles and rubber gloves, and five brief nurses’ visits-had run $6,364.25. The doctors’ fees were $1,755.75.

Total cost: $15,123.08. For the flu.

Worse. Blue Cross was paying it, apparently with no questions asked-at least not of me. And that had me aggravated. I mean, here was the same company that had refused to give me $329 for my kid’s checkup, now blindly writing checks for 40 times that amount for clearly questionable charges.

So I called Blue Cross. I got a customer-service representative named Jenny. I told Jenny that the bills were alarming. I told her that even I. a lowly insurance maven, could see that a week in the hospital in a private room with a color TV shouldn’t cost just a bit more than a week at home, lying in your own bed with your own wife/nurse. I told her that I wanted to see the hospital bill because, surely, something was wrong. Surely. Blue Cross was being ripped off.

Jenny said that if 1 had a problem with Baylor. I needed to talk to Baylor. I told her she was missing the point. Blue Cross, which was paying $15,000 for flu, had a problem with Baylor. I was just offering to help.

Jenny told me she couldn’t do anything.

My favorite insurance company was living up to its reputation. Disgusted, I considered letting it go. But the Blue Cross missives kept stacking up. and 1 knew that Baylor was getting its money as surely as the world was facing higher premiums. So I called Baylor.

I talked to a Mrs. English in accounts payable. She said she could only send me a bill for the hospital stay: Baylor HomeCare. an affiliate of the hospital, handled the home IV therapy. Cindy at Baylor HomeCare said | she only handled the nurses’ visits; the drugs and equipment came from HMSS. a Baylor HomeCare subcontractor in Houston.

Diannia Young at HMSS was surprised to hear from me. a lowly wife/nurse. “This , really has nothing to do with you.” she said. “It’s between us and Blue Cross.”

I pressed on. I asked Ms. Young for a breakdown of charges over the phone. What she told me surprised me-it turned out that most of the bill, more than $5,000 of it, was | for two antibiotics. Bingo. I knew we’d only gotten one antibiotic. Ms. Young didn’t believe me. She said she’d check into it.

As far as I was concerned, more than half of the HMSS bill had now been eliminated. But the remaining cost of the one drug was astonishing; 19 doses of ganciclovir, a potent drug not normally prescribed for flu, had cost $2,234.02. I called Baylor’s in-house pharmacy, where a pharmacist and I com-pared prices. Baylor had charged us $45 | for one dose of ganciclovir when we were in the hospital; HMSS had charged us $73.95 for it when we were home-plus $43.63 just to hag it. But there was more. For example, HMSS had charged us $24.38 for an 8-ounee bottle of antiseptic hand soap-one that Eckerd Drugs sells for $6.05. It had charged us $18.26 for a cheap plastic container to throw our syringes in: they’re $2 at a medical supply store. It had charged us $17.02 for a 2-inch needle in the arm; the hospital’s charge had been $4.55. And on and on.

1 was not a happy health-care consumer. I called Blue Cross back and. after much persistence, got a company trouble-shooter named Cindi Peckham. who actually seemed interested in the fact that her employer had been ripped off. In fact, she seemed personally outraged by the overcharges. She demanded reimbursement from HMSS for the $2.931 phantom antibiotic and got back what the company had paid up to that point. She also agreed with me that the res! of the charges appeared excessive-the $24 soap, the $18 trash can-but, she explained, “the experts” at Blue Cross had found all but the antibiotics (of which they would only pay 60 percent) to be “usual and customary” charges. When Ms. Peckham was done with her work, she forwarded my file to the company’s fraud unit. She thought they might want to look at it. “I’ll bet this type of thing happens all the time.” she said, “because if the patient isn’t assertive and isn’t actively taking part in this, then all we have to go on is what we’re being told by the provider.”

Except for Ms. Peckham. Blue Cross officials were pretty ho-hurn about my experience. In the way of the insurance world, my $3,000 mistake was loose change in the $924 million the company pays out annually in Texas. Lane Mellon, the head of the company’s fraud unit, told me he encourages customers to review their bills and call his office directly if they find questionable charges. Still, my question was this-why should any of us bother? What was the incentive? What would Blue Cross do for peo-pie like us who took the time and energy to fight with Blue Cross employees in order to save (them) money? Would they lower our premiums? Give us a cut of the take?

There is a Blue Cross in another stale. Mr. Melton said, that offers cash incentives. If acustomer finds a mistake, like 1 did. thecustomer gets half the recovery. But TexasBlue Cross doesn’t offer that. It doesn’t offer a toll-free fraud hot line either, whichother stales have implemented. In otherwords, it doesn’t offer anything, which, tome. said volumes about the company’s in- ;terest in helping win the battle to cap in- surance premiums.

Shortly after Mr. Melton and 1 hung up. I got a call from my sister-in-law in Los Ange-les. She had given birth to a baby girl five weeks before, and she had just gotten the hos-pital bill. There was a charge on it for $18, she said incredulously. For one sanitary napkin.

I didn’t blink.