A True Embarrassment of Riches

January 28, 2009

I have often made the point that a major flaw in the health care  status quo – I balk at using the word “system” – is that no single entity accepts full responsibility.  With very few exceptions, everyone is trying to find someone else to pay the bill or the rest of the bill.

And too often the consumer is the rope in this tug of war.

I received a call from a member.  He wanted to drop his employment based insurance.  Why?  His wife had insurance.  Not an uncommon request in today’s market.  But some questioning revealed that it was a bit more complicated than that.

It seems the member had been admitted for emergency cardiac by-pass surgery.  After the surgery, he was referred to a rehab facility for cardiac rehabilitation.  But the rehab facility refused to admit him until they got clarification on which insurance was primary.

I have determined which insurance is primary.  I think I also understand a possible reason for the confusion.

I can not determine why a provider would deny care – or even suggest that care might be denied – when it was clear that one of the insurance companies would cover the services.

But that’s the way it is when everyone is looking for a way out.


A game of Old Maids

October 18, 2008

Approximately six months ago our office began receiving stacks of paper claims for prescription drugs.  The drugs originated in various Veterans’ Administration medical centers around the country.  They were for drugs that members in our Plan had received at VA medical centers. 

It was obvious that there had been some sort of new policy at the VA that required the VA to obtain payment from other payers when veterans had other coverage.  The problem in this case is that our Plan had just changed pharmacy benefit managers effective January 1, 2008. 

So think about this.   Read the rest of this entry »