I have been lucky enough to have OK medical coverage through my employer for many years now. But...my share goes up and up, and it keeps changing and getting more and more complicated. That so many people actually fight Obama on trying to improve this system I can not understand at all. The fruit cakes!!!
I guess the company I was the happiest with, was Pacific Care, and Sharp Mission Park. It was the first time I felt like I had one place to go to handle most things, and I did not have a lot of out of pocket costs or paper work to deal with. I had a reasonable co-pay for some things, the rest all just got paid. Like magic.
Maybe 2 years ago, my company switched to Blue Cross, and around that time Sharp Mission Park, became Scripps Coastal. I was not thrilled, but did not want to change to Kaiser. People either love or hate Kaiser, there does not seem to be a big in between group. My wonderful Pacific Care Dr. had moved away, but many things about the group stayed the same, and I stayed. This last open enrollment, I considered switching. I was pretty sure I would have a lot more medical expenses this year, and spent quite a while looking on line, and making some calls. I couldn't figure out what the new co-pays would be, or what surgeons were still considered in my network. Decided to stay with what I had.
Now I am preparing for Major surgery. My hospital co-pay went from 0 to $200., and they prefer that I use Scripps hospital, rather than Tri-City that I used last time. Scripps is newer and nicer, but further from me and most anyone that would be giving me a ride. Plus the last surgery I had there resulted in nerve damage. Maybe just a coincidence, but why not go where things went well last time, and are closer? But if the co-pay is a lot more, I will go to Scripps.
The surgeons schedule person explained that things have changed a lot with my insurance, they no longer have to get referrals, and prior authorization from my PCP, now they go right to Blue Cross.
One of the complications is my insurance card now lists 2 co-pays for office visits, and two different ones for specialists. I had no idea which was which. The surgeons office charged me $25. co-pay. OK. Then I get a bill asking me for $15. more, saying my co-pay is $40. OK, that's a lot. Plus if they were wrong about that I better call them and check out some other stuff.
First ask for an explanation of my two co-pays. Apparently my co-pay will always be the higher one because of the medical practice. When I went on line to research and check before choosing, I should have noticed if the practice had a little ribbon icon next to it or now. A ribbon means I pay the lower co-pay, no ribbon means I pay the higher one! And I would know that how??? My co-pay is the same at either hospital, provided my medical group gets a referral to Tri-City before I go in. If they fail to do that I would be expected to pay everything!! The whole $56,000 or so cost.
So I call the surgeons schedule person back and say I have been told I need to get a referral to Tri-City from my med. group first or they will not pay, and I want a copy of that in my hand before I go there. Meanwhile, maybe I should also book something at Scripps in case they will not authorize it, so all the good dates and times are not gone.
She who had seemed quite nice before, practically yelled at me "I don't know how many times and ways I have to explain this to you, you don't need to get authorized by your med. group. Yours is not a true HMO, we go directly to Blue Cross for all authorization, once you have gotten the initial referral to us for treatment. I do this all the time, with lots of people with the same insurance and Med groups as you. If you want to go to Scripps, fine, but you can't book both places, and tie up a spot, and its too early to get any authorization from Blue Cross. She calmed down a little as we talked. Seemed to better understand why I was so concerned. When I said I would call Blue Cross back, she gave me some key phrases to use when talking, and said if they still did not get it, ask for a sup.
So I do that. Mind you I called Blue Cross Monday, so I call back. The answers are a little different, but way closer to Mondays Blue Cross, than to the surgeon office. In my mind, the insurance co. should know even better that the surgeon who has to try and keep track of multi plans. I ask for a sup. get an assistant sup. She finally agrees that yes, the surgeon can directly ask Blue cross for an authorization, and that should not be a problem, and they can ask for anything while I am in the hospital, but before or after everything has to go back to my PCP. (who did I mention I have only seen twice in my life, and am not that crazy about?).
I am totally visual. I prefer making all my phone calls from my private home desk, with a note book and anything I need to refer to in front of me. My med. group closes 11 minutes after I get home from work. The hold time is usually 10 minutes. I have yet to discover any after 5 or on weekend number besides the answering service. At least the surgeons office and Blue Cross I have been able to actually talk with after work.
I am already a wreck dealing with everything I need to do to prepare for this surgery and recover, esp. with having a few remaining animals, and living alone, with no family around, and way less friends than I had last time I went thorough all this. If I go with the current Tri-City date....its 3 months from tomorrow!!!!!.
By then I want my filthy house clean. My badly overgrown yard tidied up. I am used to doing everything or it does not get done. Lots of bad experiences trying to hire help. I work full time. I am still way behind from being too depressed about my ducks to do much of anything. Trying to force myself now in prep. for the surgery, but there is tons to do. I am slow, and in pain much of the time. I don't want anyone to see my house. I need a ride to the hospital and home. I would prefer it not be with a stranger. I need a ride back to the Dr's. at 2 weeks, and at 6, then I should be able to drive again. I need a ride to the first physical therapy season. I need someone to take care of my animals while I am in the hospital for 4 days, and to help me with them for 6 weeks. The bunnies are not that difficult, but cleaning my disgusting turtle tank...unless you have done it, you have no idea how gross it is. I don't see how I can do it before 6 weeks, yet not comfortable sitting on my butt watching, while an acquaintance does it for me. I have 2 cars and a 1 1/2 car drive way. I need someone to start my cars up a few times, maybe move them a little, so I am not ticketed for being in the same spot in front of my house too long, Someone to take the trash out the first two weeks. Actually groceries are the least of my worries. I can stock up on most things, and the rest that is something more people are OK about helping with. Getting your own meals with a walker is difficult, but I managed last time. Though they were usually cold by the time I got them to the table. The walker part should only be two weeks. The no bending part is 3 months. Doing this in summer so I can skip socks, but there is always something, like changing my sheets, or forgetting my clean PJ's are in the bottom drawer, etc. So this is why people stay in relationships...just for help getting through stuff like this. Its just the first 6 weeks. But I will be such a basket case before then.
I will need help putting the stupid white support hose on and off for two weeks. Help washing my hair a time or two. I will probably need the dressing changed a time or two. Someone here at least the first time I shower. Even if I hired a home health care person, I only need like an hour a day, and there is probably a minimum. I don't want to throw away money just to meet the minimum, and don't need a baby sitter. So far the only person who has volunteered to help at all besides working full time, is super busy being super woman, and I am already kinda uncomfortable with. Appreciate the offer, but personal care too? Damn this all stinks. I had a lot of people say they would help last time, yet I still felt I was pretty much on my own, and hoped for more support next time. Instead I have way less. How did this happen? Lots of people way more "difficult" than I am have all kinds of support. Why not me? How did things get this way? People keep asking me if I have someone to help me. When I admit to my utter embarrassment that I do not, they don't know what to say. Its not like they want to volunteer. Then quit asking. I am a rock, I am an island, but feeling rather mossy lately. Or maybe just cracked. At least moss is having a relationship with the rock.
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