Back in November, you may recall that a gangrenous vestigial organ was cut out of my abdomen. 105 days later, I think I can finally say that the claim has been processed to the satisfaction of both the hospital and the insurance company. This has required a nontrivial amount of back and forth between myself, Aetna, the Norwalk Hospital, my local benefits coordinator, and by extension our insurance broker.
Within a couple of weeks of the surgery, I got my first Explanation of Benefits. Unlike the hospital, the surgical office was extremely prompt in getting information to the insurance company. Unfortunately, in a lot of pain and a few hours from dying, I didn’t think to ask the emergency on-call surgeon whether or not he was in-network. I guess that’s what I should have asked when he asked me if I had any questions. The same probably goes for the anesthesiologist for those taking notes. He or she will also ask you if you have any questions, and you might want to find out if they’re in network too. Chances are they are not. I don’t know what I would have done had I the foresight to ask these questions, since “can I wait until somebody in-network shows up?” seems like a dumb question when you’re about to die.
So, my first explanation of benefits covered about 15% of the overall cost of the surgery, and largely related to the surgeon’s fees. Since the surgeon wasn’t in-network, that meant I paid over a grand out of pocket.
Incidentally, during intake the person doing my intake clearly wanted to go home and wasn’t really paying attention, so she transcribed my address incorrectly. I could forgive her for not being able to understand me through “AUGGGGGGGGGGGGGGGH I’M DYING,” except I handed her my driver’s license to read from. So, in all honesty, she was just completely incompetent. This made matters interesting because my billing addresses with all of the various medical facilities and companies involved in my ER intake and eventual surgery had the wrong address as a result. One might think since this was the “Norwalk Hospital” and everybody involved was part of the “Norwalk Hospital System” that this would be one entity, but no, this is the American medical system. I still don’t understand how the various entities, companies, and facilities fit together. This ultimately had no impact on the billing and claims process, but it did mean I had to spend over an hour and a half on different phone numbers updating billing information. This was important to me to make sure I actually got the bills and my credit wasn’t destroyed by somebody else’s incompetence. Not that that’s happened before or anything.
January rolls around and the first more or less full EOB shows up, covering the remaining five-figure sum. The claim lists a bunch of charges and has a half-dozen explanation codes for why nothing is going to be paid. Mostly they say nothing, beyond “the hospital hasn’t gotten us something we asked for, so you’re responsible for everything.”
Now, I got this on a Saturday originally, which sent me into a fit, so I tried to deal with it on Saturday. Of course this is impossible, because Aetna doesn’t answer their phone on Saturday, and neither does the hospital’s billing department. Furthermore, the EOB provided no guidance on what to do to resolve the situation, beyond mailing the information directly to Aetna. I have no idea what I’m supposed to mail directly to Aetna, but I’m sure glad that it’s my job to do that, or else the claim won’t be paid.
I talked to Ann the Virtual Assistant on Aetna’s site, and she indicated I could fax Aetna information about the claim, and I did so. In fact, I provided an answer to each of the seven items required in order for them to process the information. Fax machines. What the fuck. But I did it. I never heard any acknowledgment or response from this, because fuck you? I guess.
Weeks pass, nothing happens. My benefits coordinator at work offers to look into it, and lo and behold a new EOB shows up a few days later. It indicates most of the stuff will be paid and I’m not responsible for the rest of it. It’s now mid-February. Hooray! I can put this behind me. There is a note, though, on this claim. It indicates that if they can’t get an answer from the hospital on the remaining items, they’ll reject the whole claim. Nothing to worry about, right?
Late February, a new EOB shows up rejecting the whole five-figure claim. It even comes with the nice line item of “You owe $xx,xxx.xx.” Knock knock. Who’s there? Aetna. Aetna who? Surprise, fuck you! Or something. Yeah, the hospital didn’t come through, so you’re liable for everything. Aetna says call the provider. The provider says call Aetna. The broker says they’ll call Aetna, but suggest I call the mailman, who killed the barber with a shoe in the foyer. But at least they all agree on one thing: I’m liable for everything if I can’t magically get everybody on the same page.
Honestly, the details just aren’t that interesting and I won’t continue to drone on, but after a few more rounds with all of the involved parties, things eventually got resolved. I believe as of today everybody agrees I owe nothing, and supposedly the hospital was paid and it’s happy with what it got. I retain some nervousness that some other legal entity or corporation involved in my surgery will come out of the woodwork at some point to come, but I’m going to try to forget that fear for now.
I don’t have anything interesting or unique to say, really. In America, it’s the patient’s responsibility to pay a claim if the provider and the insurance company can’t work out their differences. How does this make any sense at all? Along with the game of charging too much and then negotiating prices down to acceptable levels or charging $77 for gauze pads (link defunct), I can’t say any of it really makes sense. I’m not saying anything new or obvious here, if anything I’m beating the drum on something everybody’s aware of. My case is not unique, and if anything, it’s about as smooth as could be, by supposedly having “good insurance” and a reasonably competent hospital. It doesn’t make sense to me, and yet short of becoming a citizen of another country, I’m not sure there’s much of a chance things will get better in my lifetime.