Not for enjoyable reading:
About a year ago, I was approached one of my supervisors at work with a proposal. I had had full-coverage insurance from ABC (Anthem/Blue Cross) and was signed up with what used to be Talbert Medical and now was reborn as Health Care Partners. Everything was paid through deductions from my pay check plus an employer contribution. There were co-pays, but never anything outrageous.
But, I was getting to SS retirement age and I kept getting notices to the effect that I needed to deal with Part B of Medicare, even though I had full coverage insurance, which legally exempted me until I actually lost that insurance.
The proposal my super offered was to replace the ABC insurance with Medicare with full prescription coverage via Cigna and, in addition, pay my Part B of Medicare and add a supplemental from ABC to cover the “gap.” The supervisor had drawn up a chart listing the advantages, such as zero co-pays for doctor’s visits. Everything was supposed to go like clockwork. And, it dovetailed into the changeover in doctors as well, as my personal physician was moving into management.
Except that the SS/Medicare office kept losing my file. Every time I called them to resolve the one outstanding issue – that they wanted me to back-pay for the time they wanted me to start paying the Part B, and/or suffer a major penalty, even though I had been and was completely covered by ABC for that entire period – I got a different person with different advise. Sometimes they would have some of the paperwork we – the company insurance agent and I - had filed, but often it would have relocated to some other overburdened desk, essentially untraceable. (one Medicare rep was kind enough to divulge that they were overworked, as their workforce had recently been cut by 40%, and that chaos had naturally ensued).
Meanwhile, I often couldn’t reach the company insurance rep and messages crissed and crossed between him and my supervisor, who was loath to put his name on the simple certification of prior coverage, and SS/M and myself, and I was spending hours on the phone trying to get things in order, which did not make my employer happy. Any presumed benefits in pocket change like co-pays were easily eaten up for the next year or two by the time and pain involved in the process of one simple verification that SS couldn't keep track of.
However, after that, for the past year, things have been going reasonably well. Then I realized that it was probably time for some blood work. First, I kept seeing these ads for Shingles Vaccinations at WalMart and other pharmacies and I asked my new doctor if I should get the shot, and, while I was feeling ambitious, why not check into what other shots I might need? He agreed. So, that required it’s own immunology blood work, to establish if I actually ever had or was exposed to various illnesses.
Then I recalled the undone blood work for cholesterol, platelets, tri-glycerides, etc., that I usually had done once per year, as I had been under medication - a statin - that requires monitoring, and now I was off it, due to side effects. So, I called back to the doctor and got the authorization for that as well, and got an assurance from the office assistant that the requests would be combined. I made sure to get an assurance that the tests were covered by Medicare. Now came the first glitch.
Health Care Partners, under whose umbrella my doctor works, had decided to farm the actual lab analysis to LabCorps, apparently some time ago, with the option of going to any of their facilities for the actual blood drawing. LabCorps (LC) is a HUGE medical testing and research company, on the S&P 500:
I would have preferred having the blood drawn at the Health Care Partners facility in Fountain Valley, California, whose competence and hours used to be excellent. But HCP had moved the lab to a much further away location, and also limited the hours, requiring a long trip during working hours on an uncertain ancient motorcycle. However, HCP had another option. Go to any of the many LabCore offices, some of which were local and had extended hours. This seemed like the logical option. I was again assured that this was all standard procedure, covered by my Medicare plus Supplemental.
The LabCorp facility at Ist and Tustin (100 N Tustin Ave., Tustin, CA 92780) did not look S&P 500, at all. It was old and not very clean. That was the first bad sign. The guy who finally noticed me standing and waiting spoke poor English and denied that they had received the test orders at all. I had called three times to HCP during the previous week to verify the sending, because the first couple times, when I called LabCorp to verify, they couldn’t find it in the computer system.
I do IT – web design, and I knew that HCP was in the process of moving their main location, as well as having a LONG history of computer glitches with the system they switched to a year or so ago. However, I had an ace up my sleeve. Cleverly, I asked, don’t you have a fax machine? My doctor’s office had agreed to also send both requests by fax, and I called the LC facility the day before to verify they had received them. After displays of annoyance, the guy at LC hurried through the huge stack of unsorted faxes, until he found the authorization.
At last, things were working. I wondered if LC had ever heard of a filing cabinet. I asked specifically if he had found BOTH requests and described them to him. He insisted that everything was in order. So, I was guided to the blood room and put in a chair designed for someone with a completely different body type, either a foot or two taller, or much smaller. My bad knees went into total PAIN in seconds. Finally the guy arrived to take blood. His smock was patterned with random blood stains and icky yellow stuff. By this point, I was beginning to become anxious. The furtive, hostile attitude of the two employees of LabCorp was not very comforting. But at least the blood drawing went well.
I asked the drawer if there weren’t more items, as three sample bottles of blood did not seem enough, based on years of experience on my part. He assured me that it was enough. I asked him if the urine was enough, as I was a little dehydrated and had not realized that my doctor had added it to the list, and he assured me that it was fine, as well.
So, we waited for results. The first set, related to cholesterol, etc. had come in with the report that everything was fine. This was a bit unsettling, as I have a life-long low immune system, and always have had to argue with my doctor about getting a specialist on board, as I’ve already wasted hours and $$$ on that fruitless chase. If my white cell counts were fine, then either I have had a miraculous transformation, or there’s something fishy on LabCorp’s side. But where were the immunology tests that we wanted before I started with any vaccinations? We were told that they took a week or too longer.
They LIED. The blood was never drawn for the immune section. LabCorp finally admitted that this was the case, meaning that both the LabCorp employees probably lied, about having the authorization – which was probably lost from the overflowing stack of faxes – and about doing the blood drawing.
So, this time I chose a facility in Irvine, which I assumed would be a bit more professional. THEY couldn’t find the computer file, until I spent ten minutes going over everything with them, and suddenly they found it. Problems over – right?
Then, last Thursday, I get a letter from ABC, the insurance carrier for my Medicare Supplement.
“THIS IS NOT A BILL” is always somehow reassuring, but the “Statement of Benefits” (SoB) was much less so, itemizing two sets of blood work, for a total bill of nearly $900, captioned “It is your responsibility to pay.” The itemized billing listed only the bare, two word, tag – eg., “Lab Chemistry”. There was no hint as to why ALL of the blood work was denied coverage by Medicare.
So, I called Anthem/Blue Cross and spent an hour or so on the phone with a customer service rep, only to learn that ONLY those charges that Medicare allowed were eligible for the ABC supplement. He also described the situation I was in, finally telling me that the ONLY person who could straighten Medicare out as to why my doctor, a physician, should not be qualified to authorize various things, such as the taking of the blood to begin with, was my doctor. The ABC rep also mentioned that going to Medicare was probably useless, as they would just reiterate the same info as on the SoB.
The final advice from the ABC rep was for me to ignore any bills from LabCore and wait for them to decide to bargain. He suggested that LabCore would probably agree to accept the medicare rate, which would be about $125 as opposed to $900. At some point I realized that this would probably not happen, as it was obvious that LabCore stood to profit by nearly $800, or ~600% increase by keeping me at the uninsured patient rate.
Suddenly, at some point, everything made sense. Health Care partners creates a firewall for charges from LabCore, even though they have their own partnership with LabCore (as it turned out) – but only for the qualified patients, such as on an HMO. This doesn’t keep them from printing out lists that only show LabCore locations and giving them to Medicare patients, implying a special relationship or recommendation. LabCore can then write up the description of services for Medicare that guarantees that Medicare will reject the claims. Then, instead of $125, they can get $900, just for altering the descriptions.
So, I called my doctor’s office, where they informed me that they had nothing to do with the Medicare claim which had been totally denied, as that bill went directly from LabCore to Medicare. The doctor was therefore not in any position nor had any responsibility to correct incorrect information submitted by LabCore, even though it, in theory, could only have come from him.
Nor was I able to get any detail on the doctor’s orders for the blood work, which had to be the source for LabCore’s own labeling, which was what Medicare used for their decision. When I brought up that matter, I was connected to the Billing agency for Health Care Partners, which was not pleasant. The agent came across as hostile and the only thing I got was that IF I had stayed as an HMO patient with them, instead of opting for Medicare, then this would have been covered in-house via Health Care Partners or Talbert billing.
When I called LabCore, they refused all but the most basic of information, which was that I should call Medicare, who will then do the same thing as originally, lacking any updated information. LC, who sent that actual description ( or NOT) of the basis for the billing, denied any responsibility and refused any possible attempt to correct the info, or even allow me to know what it was.
Part Two: Attempting to Reach Medicare: The Non-Existent Medicare Fraud Division