12: Health insurance woes

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Remember how I said last week that I recently had a health insurance claim victory after being on the phone with them on and off for 15 months and that the next claim I submitted (same service, different date), they declined.

Yeah, I take everything back. 

Turns out: these people still don’t know how to do their job, because I thought we had worked everything out. They’re now claiming that the initial reimbursement was issued in error and they want that money back and they also won’t reimburse any of my other claims.


I won’t bore you with all the details but what this comes down to is this whole thing about in-network and out-of-network providers. I think that’s one of my biggest pet peeves about the healthcare “system” in the U.S. (and we already have a PPO plan for that reason).

We had multiple instances in the past where certain services by a provider were covered in an inpatient setting, but then not covered in an outpatient setting. I don’t understand why insurance won’t cover the same doctor in different circumstances.

(This is a rhetorical question, I understand why, but I don’t ‘comprehend’ it, if that makes sense.)

If you receive care in an in-network facility by an out-of-network provider, shouldn’t you be able to continue care with that provider in an outpatient setting?  Why would they make you go to a different provider for aftercare?  Working with a doctor/counselor is hugely a matter of trust and comfortability and the fact that they don’t allow you to continue working with the person that you’re already comfortable with is just ridiculous. It disrupts the whole process of continuing care and recovery.

I was told that we could get a partial reimbursement if I upgraded to a higher health care plan.  BUT the catch: The next tier up would be an increase of almost $200/month and a $350 deductible on top of that, which, if I do the math, makes NO SENSE WHATSOEVER (the monthly out-of-pocket costs are <$200 right now). Why would I pay higher premiums AND a deductible before I get any benefits? I can’t see a scenario where that would make sense (although I guess, maybe it would if we anticipated higher annual expenses than we currently do.)

Right now, I am just furious because they make us choose (once again) between the provider we feel comfortable with and covering any of the expenses.

Does this kind of sh*t get you all riled up too?
Can I ask how much you pay for health insurance every month?

  1. Don’t get me started on health insurance in this country. It’s essentially a scam to suck money out of us as much as possible. If the insurance companies – which are the “middle man” so to speak – were completely cut out, we wouldn’t have a lot of these issues. It’s why they lobbied so very hard when the ACA was coming out and put all sorts of demands, twisting and turning it so much in their favor that we still have a very crappy system. Medicare for all I say. Cut out the middle man.

    I can’t recall how much we pay each month for health insurance (we are on my husband’s plan – the three of us). We are also PPO and still have had to pay ridiculous costs. We just can’t win. Ever. Not under this system.

    I really do hope this will be resolved in your favor.

  2. Ugggggh. Health insurance is so maddening. I had major issues when I was relocated to NC as I had to change plans mid-year since the plan I was on in MN wasn’t available in NC. But I was still covered under my old plan for the first couple of months and saw a couple of providers but then they ‘closed’ my plan before the providers sent in their bills and they wouldn’t pay them but the new insurance company wouldn’t pay them either since I wasn’t under their coverage at that point so I had to pay them out of pocket. I was LIVID and I spent so much time on the phone with insurance companies. It’s just a terrible system.

    I’m going through enrollment right now and we are trying to figure out if we should go on Phil’s plan this year. My insurance is actually quite affordable compared to what others pay. I will pay $140/pay period (I get paid bi-weekly), so $303/month. That’s for a high deductible plan with $3k deductible, $6k out of pocket for Paul and me. Phil was on his own plan as his company generously pays his premiums (although that might be changing). So we might move over to his plan but we are waiting for more info about whether he will pay a premium and what is out of pocket/deductible is. Health insurance is so dang confusing!

  3. This is infuriating. I’m dealing with some similar albeit lesser issues with my health insurance company, & it’s absolutely awful to try to navigate. I hope you can get yours sorted soon!

  4. So sorry to hear about your troubles! The healthcare system in this country just completely sucks in so many ways! I have nothing positive to say about it, despite having good insurance by U.S. standards. Friends and family in Germany will still shake their heads in disbelief about all the co-pays and the lack of choice in terms of providers, not to mention the amount we pay. If people realized how much better services (in general) are in so many other countries, we might have a revolution. Sadly, too many people are clueless about how things could be and do not even realize how much this system sucks.

  5. Wow, that’s so awful. I’m sorry you have to deal with all of that. Health insurance in the United States is kind of ridiculous. It rarely makes sense, and it leave so many people going to places they don’t feel comfortable or not going to the doctor at all (I have a friend that has no insurance and hasn’t been to any doctor in years!)


  6. Girl, don’t get me started. Lol, I’ve had insurance through the marketplace for about six years and it’s been nothing but headaches. I’m now paying ~360 a month for very basic coverage. This is a good time of year, however, to make any last minute appointments since you may have already met your deductible. I’m told my recent surgery was 100% covered, but I never believe anything.

    Also it’s so counterproductive when you think of the fact that people don’t like changing providers and caretakers when they find someone they like. Why make it so difficult to stay with that person?!

  7. Dear god, did my entire comment just get deleted? Bangs head.

    1. It ended up in my moderation folder, God knows why?!

  8. Ugh. I’ve been lucky and haven’t had to deal with health insurance woes like this, but only because I haven’t had to deal with any crazy provider issues. Every now and then, I’ll have to submit a receipt for my flex spending account, but it usually gets approved after that. That has to be so frustrating!

    I am on the most affordable plan through my work (it’s about $45 a month) because I’m relatively healthy and don’t have dependents. But everything is MUCH more expensive through this plan – like, visiting an urgent care is $70 and specialists are $50. And I think my deductible is $10,000, haaaaa, so I’m screwed if I ever end up in the hospital for a long-term stay. Thankfully, I have a flex spending account and I put $1,000 into it every year, which covers all my copays and the like. For me, though, it just makes more sense to pay less for health insurance and have to pay more OOP, since it’s very rare that I have to do that.

  9. I am so sorry you are going through something so maddening! I do not know how much I pay per month… it gets taken out of my paycheck and I just don’t check. My husband and I each have a $400 deductible which isn’t bad at all. Lots of copays though.

  10. Bin ich froh in der Schweiz zu leben. Wir haben teilweise auch hohe Kosten und die Prämien steigen jedes Jahr, aber die Abwicklung (wie ich sie bis jetzt erlebt habe) ist wirklich sehr einfach und unkompliziert. Das muss ja der Horror sein mit den Kosten und dem Handling… Drücke dir ganz fest die Daumen, dass es irgendwie doch noch klappt. :-*

  11. All of that is absolutely ridiculous, especially because I’m pretty sure you have federal health insurance that should not be this complicated. It’s insane, all of it, the entire insurance industry. It’s trash, it doesn’t work and even though I’m very blessed to have great insurance, I know I’m one of the lucky ones.

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