And Now, The Rest of the Story…

This will be my final post about my personal odyssey with the fine folks at Anthem. It will be brief, just to update those of you who’ve been so kind with your suggestions and good wishes.

You will be happy to know that Anthem has made medical school unnecessary.

Yep–when they finally returned the multiple calls from the hospital doctors, and those doctors had once again gone through the charts, the X rays, the reports from in-hospital PT, etc., they were told that according to Anthem’s algorithm, I am not a candidate for rehab.

Their algorithm, you see, knows more about my condition and needs than the medical personnel who actually examined and treated me.

As one doctor said, “why did I waste all that time in medical school?”

I’m going home. My younger grandchildren will come over to help my husband with my care, at least for a couple of days, and we’ll figure it all out. (As those of you who know me know, I’m a tough old bird.) But everyone in this situation–as you  can see from the multitude of comments here on the blog and on Facebook–isn’t as fortunate as I am, doesn’t have a support network that can step in. And according to the doctors and caseworker, I am far, far from the only person facing this bureaucratic malpractice. And I will follow up on several of your recommendations for filing complaints, etc., in hopes that I can keep at least some others from going through a similar fiasco.

The United States is the only developed country in the world that has chosen to socialize its medical care through the insurance industry.

I asked one of the doctors if they have these same problems with Medicare. They don’t.

For now, this blog will return to its originally-scheduled programming.

 

 

36 thoughts on “And Now, The Rest of the Story…

  1. Whew, was a little worried about what would happen to my Anthem stocks if they paid. Lobster and Champagne for dinner tonight! Won this round.

  2. Countless thousands of doctors are owed some big refunds for the money they spent for medical school, many of whom will never get out from under that enormous debt. They need not look to Anthem for their refunds.

    You just take care, get well, and let the kids and grandkids fuss over you. Take no chances now…you know that Anthem won’t be there for you!

  3. Thanks for sharing your experience with all of us Keep up updated on your progress. The health insurance industry is slowly strangling itself as it denies its policy holders and medical providers. Thank you for giving voice to the problems so many others have experienced. As usual, you are the champion of those who need one.

  4. My mom has Medicare and TriCare…she is going to a holistic MD who is running all these tests….she had to collect poop for days. I warned her to be careful as I don’t know of one insurance company that will pay or cover these tests. My friend goes to a holistic MD and everything is out of pocket but my mom’s stuff is actually covered. Medicare is known for low pay but it doesn’t seem to come with the hassles that private insurance comes with…

    I just spoke to a chiropractor who dropped Cigna. The patients co-pay was $25 and Cigna only agreed to pay a total of $27 for an adjustment thus he would receive $2 from Cigna. Cigna told their patients they can have 20 adjustments per year but on the provider end they would only allow for 4 adjustments and then he was required to fill out a 15 page report justifying the need for treatment and what he did and IF they felt more adjustments were needed they would authorize only 2 visits and he would have to fill out the paperwork.

    My Medicaid peeps had it better when it came to drug coverage that is after they decided to consolidate all the forumlary’s where they were all operating from the same forumlary as oppose to 8 or more.

  5. I hope you will have a proper recovery. The stress alone must be horrid. We live in stressful times in this country.

  6. Did they at least approve some in home PT? They have to at least do that. I hope the move home goes smoothly and that you recover quickly.

  7. From experience, they often defend themselves by point out Anthem does not make medical decisions on your behalf. (Uh, how so??) They’re quick to point out you are in fact welcome to follow your doctor’s advice and attend rehab at full rate prices, they’re just not going to pay for it. Practicality says you’ll go home and hope for the best of course! Sadly what they’re doing sits at the intersection of completely unethical and yet perfectly legal.

    Here’s a fun one: I had a (young) sibling who suffered a stroke and the most ungodly hospital infection in medical history afterward. It landed her in an extended care facility (ECF) under private insurance from her then employer. She was just mobile enough that we could get her out in a wheelchair and as her family we thought an afternoon outing would do wonders for her spirits. I set up the trip and got a frantic phone call from the ECF Social Worker saying, “You can’t take her out of this facility for one minute!!!” Her docs, nurses, and she herself agreed she was up for it. So why not? Answer: If we were to take her out even for an hour that would, according to the insurance company, prove she didn’t need to be in the nursing home and they would sue us for fraud, demand repayment of all her bills, and in the process drop the accreditation of the nursing home under their company’s plans. In short, “You do something nice to help this patient recover and we’ll ruin your life.” The social worker assured me it was completely unfair, but the threat was very very real. As if it wasn’t enough for us to nearly loose her life and have her in a care facility, we were now threatened with lawsuits for trying to help her enjoy what remained of her life. Let that sink in.

    Oh I almost forgot…when the private insurance ran out and she went on Medicaid she could then leave the facility for up to 3 days to spend time with family, etc.

    While I’m here Sheila, I wonder if you know if private health insurer’s are doing as cell phone and cable companies do and require that disputes be handled in private arbitration and you are denied access to the court system? The Supreme Court has held that up time and again as being legal.

    This is all a reminder that The Golden Rule is not “Do unto others as you would have them do unto you,” it’s “He who has the gold, rules.”

    All that awfulness aside, I hope you have a swift recovery!

  8. Sheila, I posted on FB yesterday, and encouraged you to file a complaint.

    I don’t have the support network you have. I’m widowed, I have very elderly parents, and an adult son with mental illness. I have no advocate; I have no excess of money; I have no caregivers. If I were in your exact medical situation, they might as well euthanize me. I’m sure Anthem wouldn’t cover that either, but I’ll be certain to set enough aside to cover it myself.

  9. Here’s the problem. We got way too used to nobody worrying about healthcare costs except the Employee Benefits Department and the CEOs of insurance companies charged with make more money regardless of the impact on others.

    That inattention predictably got us here to where we can’t afford what can be done for us. Oh a few of us can but it’s a decreasing percentage.

    Something has to be done or more and more of us will have to sacrifice longevity or quality of life because of money.

    The good news is that many countries have shown us how to avoid or at least delay the problem. The bad news is that we’re highly resistant to learning.

  10. Fundamentally, I don’t understand how non-medical professionals are allowed to determine what his medically warranted. What is to keep them from denying everything? There must be statutes that cover this?

  11. I’m livid on your behalf. And happy that you have a family support system – and likely neighbors – to get you through rehab at home. Too many Americans today have neither, with our families strewn across the country or overseas and our ‘trust no one’ attitudes that build walls between neighbors.
    Once you can manage it – the best rehab in the world is swimming.
    All the best to you and your family.

  12. There is no reason but greed by the insurance company to deny the tgerapy your doctir prescribed. You are indeed fortunate to have your family support system. I’ll pray for your speedy recovery.

  13. Andy, non Medical people can’t make medical decisions but can financial decisions. Healthare insurance companies are run by accountants not Drs. Wealthy enough people don’t need health care insurance. Only those who can’t afford big financial risks do.

  14. That’s plain BS (yes I kept it clean). As a person that has had a friend in one of the best rehab hospitals in Indianapolis, I have seen the GREAT work and need for rehab. I’m sure, unfortunately, your case needed rehab and you could have benefited from it. What if you lived on your own, had no family in Indianapolis here or people that could have helped you….would they still have discharged you to home?

    Glad I’m not with Anthem any more. Sorry for your circumstances Shelia, if your caregivers need help I’m one of the host of people that would be willing to help.

  15. Andy and Pete; politicians and employers have been making medical decisions for women the past few years, why can’t accountants at insurance companies be allowed to make medical decisions?

  16. These are the people that we want to absorb other health insurance companies to give them more power to tell our physicians how to practice medicine. They have a guaranteed 15% profit margin built into their business model. For comparison, Medicare services calculates about 3%. That means that 12% of the health care dollar is spent on non-medical expenses, such as marketing, acquisitions and profit for the share holders. Very disappointing.

  17. So sorry, Sheila, but glad you’re getting out of the hospital. My husband and I have never had problem one with Medicare. It’s time to not only deal with Wall Street but also with insurance companies. Get well soon.

  18. My employer generously pays for my Anthem premium which is over $1000/ month. I have a 1500 dollar deductible and $5000 out of pocket for OUTPATIENT services. This year I spent just under $6500 in out of pocket expenses. I was just told by the tax accountant at H and R block that if I had had about $100 more in out of pocket expenses that I could have gotten the health care tax deduction. I am an RN and of the opinion that our health care system is a corrupt, profit mongering system. I’m so sorry that you are having the same painful experience that many Americans have had. It’s a violation of the Hippocratic Oath “Do no harm.”

  19. It’s good that you have family to help you out, but this is not equivalent to going to a rehab facility because at a rehab facility, you could undergo professional physical therapy multiple times every day. Yes, you could have your family drive you to a PT facility several times a day, but this is far less effective and convenient than being on-premises. In addition, you would have nursing staff to assess your wounds, check your vital signs, administer your medications and such facilities have clutter-free halls with rails, assistance with toileting and bathing and meals, so your family and friends are free to concentrate on visiting, bringing treats and shopping for greeting cards and flowers. Having a visiting nurse or therapist isn’t the same.

    A fractured pelvis is a big deal at any age, but even more so for older persons. These places are NOT nursing homes, and they serve a vital function. Studies have shown that rehab after hospitalization actually lowers health care costs because they reduce the incidence of complications. Of course, insurance companies had to learn this the hard way, by forcing out patients before they were ready, only to have them return with complications. Also: why wouldn’t Medicare cover rehab, since you’ve been hospitalized for 3 days?
    Natacha, R.N., M.S.N., J.D.

  20. This kind of thing is basically par for the course with all private insurers. Contact your state Insurance Commissioner and file a complaint. That can help sometimes. The business model is basically to deny all care and then make you fight to get something, with the hope that you won’t actually follow through and force them.

  21. In 2005 I had aortic repair, removal and replacement of a section of my aorta. Extremely serious surgery, 50/50 chance of survival. Developed paralyzed intestines during the 6 day stay in-patient (4 days in ICU) but released in that condition. Prior to release I was interviewed by someone from Medicare regarding in-home nursing visits daily to check vitals and general conditions because I live alone. Condition didn’t improve so three days later my daughter-in-law took me back to Methodist ER; readmitted with the continued paralytic condition, unable to eat or keep even fluids down. When admitted from ER to in-patient, my IV providing fluids due to dehydration was removed…finally replaced the following morning. During the night I was moved from the bed to a gurney and pushed through the hospital, left alone in darkened hallway outside an ex ray room to wait. Finally someone began pushing the gurney; back to my hospital room because the ex ray order was for a different patient. Six more days in-patient with a second interview by Medicare; qualified the second time for in-home nursing visits daily. Released in same paralytic condition after 6 days. No one ever contacted me or showed up at my home to check my vitals or my condition; fortunately my daughter-in-law (former CNA) and her mother, a Certified Physician Assistant, saw to my medical needs. Between us, we gradually worked my way from sips of water or iced tea to sips of Ensure and finally small meals. This was long before ACA, this was Medicare and Senior Smart Choice Medicare supplemental coverage. I wasn’t formally denied after-care as Sheila has been…they just didn’t bother providing promised after-care.

    Bring back the good old days of family doctors who provided full medical care with testing or hospital referrals only when necessary and where proper care was provided. Progress does not always mean improvement.

  22. Hey, where are the right wing commentators? We need to hear them weigh in on this. I’m really eager to hear someone defend the rationale that private enterprise is sooooo much better than government bureaucrats because it’s really fun to see people twist themselves into weird knots.

  23. Thoughts to you Sheila and keep on fighting the good fight(s)! You are my FAVORITE tough old bird!!

  24. Watching the crowds cheering as the Republican candidates vow to repeal every word of Obamacare is a sight to behold. Do these morons really want to return to the good ol’ days when the insurance companies (aka death panels) ran the show? YES THEY DO and if the R’s win we’ll all suffer and we’ll all get what we deserve.

  25. I’m so sorry. I’m a newly retired nurse and echo Robin’s statement regarding corruption in insurance/healthcare. Hope you can get rehab on your own. I’d bet you can find someone by networking…perhaps someone who would come to your home.

  26. As a provider, I see Dr. Anthem preserving treatment regular. As a former insured, though I am insurance savvy, I find it nearly impossible to acquire more than a summary of benefits before or after purchase of a policy. I makes me wonder if a significant portion of the anger in the public is about the state of healthcare. But the system is so complex that people gravitate to concrete, black and white issues they can understand. Then they blame insurance companies or health care providers, or others, rather than holding politicians accountable for supporting an unsustainable healthcare industry.

  27. I have no idea what you’re all talking about, America has the best healthcare system in the world! All the wealthy politicians agree!
    But yeah, I can’t wait for the reactions of the rabid masses of Republican voters screaming for repeal of Obamacare, when they discover that things like KyNect and expanded Medicaid go bye bye. And then they get denied private insurance due to their preexisting conditions.

  28. I’m so disgusted (for you) that any more words wouldn’t be fit to share…except complain, complain, complain.
    Get well soon.

  29. JoAnn described an example of things to come if liberals achieve their goal of single payer. Sheila’s plight, as summarized, is an outrage, but today there are other companies and potential legal remedies for such outrage. Single payer will result VA level delays and mismanagement with no possible recourse. I pray for your healing, Sheila

  30. This is the same wonderful Anthem that refused to allow my doctors (at a world class medical facility, who knew their stuff) to treat my life threatening kidney tumor in the way they saw fit. Something like seven appeals and eight denials later, we went with a more invasive treatment (that Anthem would allow and pay for) rather than risk my bleeding out at any moment (literally). Was Anthem hoping I’d die during all of the appeals so they wouldn’t have to spend a cent?

    The oncologist of a late friend of mine told me that he spends much of his days on the phone fighting with the M.D.s that insurance companies hire to fend off claims. The insurance companies got tired of losing administrator vs. M.D. battles and hired their own docs to push back. We can decry the insurance bureaucracy, but recognize that the folks denying our care are people who went to medical school and promised to do no harm….

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