Anthem Blue Cross Blue Shield Approves Cardiac Rehab Stay Fit For A Time Traveler

In a letter dated March 27, Anthem Blue Cross Blue Shield informed Dona that her father was approved to stay in a cardiac rehab center through March 24. Dona’s mother began planning for her husband’s care shortly before his triple-bypass on March 15. Anthem originally approved the off-site rehab, but changed its mind on March 19, the day before Dona’s father was scheduled to be discharged. With the support of his doctors, he filed an emergency appeal so he could move to rehab the next day. The retroactive approval arrived a week later.

On March 15, my dad had triple-bypass heart surgery at Jewish Hospital in Louisville, Kentucky. My mother immediately started planning for his aftercare. My mother is disabled and uses a walker to get around; my father normally takes care of her.

My father’s doctors, along with the hospital’s case worker and my mother tried to get their health insurer, Anthem Blue Cross/Blue Shield to approve off-site cardiac rehab. They initially approved the request and made arrangements at an approved facility. The day before checkout, March 19, Anthem changed it’s mind. My father’s doctors kept him another day to execute an emergency appeal. But to no avail, Anthem determined my father was “too healthy” and would have to go home (and basically perform self-care). It pushed my mother to the verge of a nervous breakdown, but thanks to friends and neighbors they made it work. Anthem was kind enough to provide a visiting nurse, three times a week, even though daily care was recommended by the doctors.

Yesterday, they received the attached letter, approving the rehab stay. Well, great, right? Let’s go to rehab! Well, no-no-no. The approval was only good until 3/24. So, he’ll have to re-apply.

http://consumermediallc.files.wordpress.com/2008/04/anthem_is_stupid_late_and_useless-thumb.jpg?w=494&h=718

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  1. bigdtbone says:

    Anthem Accounting Dept,

    The clinic wants cash up front, could you mail me a direct check for the total sum of 4 day’s stay at a cardic rehab facility. (So I can send my daughter to law-school with it…)

    Thanks, I can haz helf karez?

  2. scoosdad says:

    …and “Lorrie C.” and Anthem doesn’t even have the kahunas to sign his/her full name. Nice.

    What a f*cking waste of ink and a stamp. What a f*cking company.

  3. Over the last 2 years, I’ve learned to navigate Blue Shits/Blue Crap insurance system on behalf of my ailing father. The only thing that is 100% effective, is making nice with the doctors, nurses, and support staff at the hospitals and various medical facilities. These people know how to work the system, and if they like you, they will find a way to help you out.

  4. thecoreyt says:

    @scoosdad:

    From what I gather by working at Unum, full names aren’t always given by people in the insurance field to protect them in the event of an angry customer. As you see in the letter, you can reach them at work but not giving the last name prevents customers from seeking vengeance at their home address.

  5. missdona says:

    @scoosdad: Yep. My dad (the cardiac patient) says that “C” stands for C-U-N….

  6. evslin says:

    Now that’s just dumb.

  7. humphrmi says:

    This is what they say is saving our health care system in America.

    Dear BCBS: I hope I am never insured with you.

  8. Imakeholesinu says:

    This is why I left healthcare. This is also why we (the US) are ranked 39th overall in the world in healthcare. The privatization of healthcare in American is the greatest crime against the public. It is not in the best interest of the american people to be treated as a dollar sign when they need to go to the doctor. Health care insurance companies should be ashamed of themselves as they are fleecing needy people out of their hard earned money, just to make the bottom line and turn a profit for their investors which are not in your or my best interest. They have too often refused care to the ill because it costs too much when you, or I, or the companies we work for, pay the tab to provide care that we depend on.

    Lobbying by private interest groups should be banned and barred. It should be illegal and those in congress or any government office who accept this should be tried for bribery.

    This is just another example of how the bureaucracy of the united states of America can screw over every citizen it (thinks) protects.

  9. humphrmi says:

    @Imakeholesinu: I’m a Republican, and yet I think your point about banning lobbyests and PACs from health care legislation is on the mark. Sadly it won’t happen.

    Not to politicize the debate, but just as a point of reference: (Arizona Senator and GOP nominee) John McCain and (Illinois Senator and Democratic nominee) Barak Obama tried to get together on campaign reform that would have at least kept the health insurance companies out of the presidential race; at some point the two of them decided it wasn’t feasible any more and gave up.

    Added to that, (and mind you I don’t know the details here, but) most of us can’t sue our insurer because of tort limitations that have been enacted by our illustrious Democratic Congress & Senate and signed by our illustrious Republican president.

    Do any of them know how much this pisses us off?

  10. @humphrmi: Republican. Democrat. The party lines tend to get blurred when there’s GREEN involved, eh?

  11. humphrmi says:

    @ceejeemcbeegee (you can call me sweetie): It’s very frustrating. I’d like my party to be more in tune with how people are getting screwed, and try to prevent it, if not at least refuse contributions from the screwers. But that ain’t gonna happen as long as candidates from both parties keep getting their soft money that helps them get elected.

  12. Benny Gesserit says:

    OK, BC/BS bad bad bad, evil incarnate, etc etc. But can I play the devil’s advocate for a minute.

    Do you think it’s at all possible they authorized those dates on the assumption she and her father found some way of getting him in there as originally planned? In other words “You said he’d be going there for date whatever to date whatever. Send us the receipts / invoices and we’ll reimburse you.”

  13. SOhp101 says:

    @Imakeholesinu: The only problem is that the people who are in office to create these anti-lobbying laws are usually bribed by the lobbyists.

    Go American Government!

  14. @Jim (The Canuck One): Erm… it usually doesn’t work like that.

    It’s not very likely that the family agreed to pay up front, thought better of it, then petitioned the insurance for a reimbursement. When a patient is discharged from a hospital, the DR decides to where in the form of a written order. Obviously, their doctor ordered for him to go to an assisted living facility. That order goes to the insurance for approval. They family gets a list of places the Dr. services and the insurance covers. Depending upon the type of insurance (PPO, HMO, Medicare) the family will be responsible for anywhere between 0-30%. The family chooses a place, the place submits their bill to the insurance, the insurance approves it, the Dr. sends along special instructions, the patient is admitted. I doubt this family bypassed all this and just picked a home, agreed to pay cash, then said two weeks later, “Oh wait, lets get the insurance to pay for this” because one of the FIRST questions they ask you at these homes is “What kind of insurance do you have?”.

    I’ve been in a similar position as this family. Your loved one is about to be discharged to a facility, all the arrangements have been made, then the insurance company changes it’s mind, inexplicably. The hospital says, “you’ve been discharged, get out!” and the assisted living home says “insurance was denied, you can’t come here”. You have no way to caring for your loved one at home. What do you do? File a grievance to force the insurance to pay like they promised and as your coverage outlines. In the meantime, what do you do with your loved one?

    The problem is often that these companies try to find reasons not to pay for things which people are clearly covered. It’s easy to say, “pay up front and wait for a reimbursement”, but these services are quite expensive. It’s not like a night at a hotel: most places range from $300-$600 per day (at least in LA they do… it may vary regionally). Special treatments, like dialysis or speech therapy up the price. And a home-care professional can cost up to $20/hour, and most of these people charge extra to do to cook the patient’s meals, administer medications, changing diapers, etc.

    In my father’s case, I had to loan my mom $3500 for the 3 weeks in his assisted living facility that Blue Shit tried to get out of paying. That was 3 months ago. Still waiting on that reimbursement we were promised.

    Thankfully, I was in a position to help. But how many families have that kind of cash at the ready, especially when there are previous medical bills and expenses piling up?

  15. landsnark says:

    This is why none of the three systems proposed by the US presidential candidates will work.

    Hillary’s, McCain’s and Obama’s system (like the current system) rely on insurance companies to finance health care, and it will never make business sense for these insurance companies to allow excellent health care.

  16. shepd says:

    Everyone who thinks US healthcare is bad, you could be in Canada, which is the equivalent of whatever you’d get healthcare-wise in the US if you live on the street without insurance. But absolutely free!

    Need expensive pills? Anything medical but dental related? Any therapy that isn’t government approved? Want to be admitted with a cracked skull in under 5 hours? Not to have to go to court for the supposedly free ambulance service (the exciting stories you learn of when you get your CPR card here)? Want to get surgery before you’re just about dead? Or even a doctor requested MRI to find out if you’re going to die? You’re selling up the house if you didn’t buy insurance, either that or it’s just not legal to get that kind of care.

    Government paid healthcare isn’t a panacea. It’s a tragedy of the commons.

    Living in a city with the worst hospital in Canada sucks.

    [www.thestar.com]
    [www.grandriverhospital.on.ca]

  17. missdona says:

    @Jim (The Canuck One): ceejeemcbeegee (you can call me sweetie) is right. The arrangements had been set with a facility that accepted the insurance, the Glen Ridge Health Campus, that it CC’d on the letter. When Anthem denied my dad, the timing was very short and the unknowns were to great for my parents to risk it financially.

    For the record, I don’t think government sponsored health care would be any better. I don’t trust our government enough to run a better system. If you haven’t noticed, they’re not the most efficient people around.

    I think the only answer to this nonsense is legislation, and our legislators suck noodles.

  18. DaffydCA says:

    Shepd – Have you actually experienced both Canadian and American health care? Somehow I doubt it… Moving from California to Ontario, I’ve had the chance to experience both.

    There are problems in both countries’ health care systems. Having experienced both – I wouldn’t say the care is any different in either. Sorry to burst your bubble – horror stories are easy to come up with in either country.

    I have never met anyone here in Toronto who had had any problems dealing with health care. I got to compare when I went into the hospital for an operation – things worked just as smoothly and quickly as in the U.S. Actually, even faster than some of my experiences in California.

    Need expensive pills? If Blue Cross of California doesn’t have em on the list, forget it.

    Anything medical but dental related – Blue Cross won’t cover it. Any therapy that Blue Cross hasn’t approved? Nope – can’t get it.

    Want to be admitted in the Emergency room? Ask the woman in L.A. who was dying and the staff left her to die on the floor. (Even after her partner tried to get an ambulance to take her somehwere else – of course they wouldn’t, because they said she was already in a hospital!)

    Want to get surgery before you’re just about dead? Not if your insurance says no. Even a doctor requested MRI to find out if you’re going to die? Not if your insurance decides it’s unnecessary.

    Sorry about the problems you’ve encountered, but it’s a major stretch to say all Canadian Health Care is like what you’ve experienced.

  19. landsnark says:

    @shepd: “Everyone who thinks US healthcare is bad, you could be in Canada, which is the equivalent of whatever you’d get healthcare-wise in the US if you live on the street without insurance.”

    First, we already have a successful government-run system in America (the VA system) and the government run system is much, much more efficient and well-run than the for-profit system that most of us are forced to use.

    Second, assuming pessimistically a US government-run system would be as inefficient as the Canadian system, how would I be worse off than I am now? I’m a working American without insurance – if me, my wife or my daughter needs a very expensive medical procedure, we WILL be denied treatment. No bureaucracy to argue with, no one to sue, no forms, just a big, fat no. For less expensive procedures, I will be charged more than an insured person (because insurance companies can bargain with hospitals for discounts), AND I get to pay the entire bill.

    So, you’ll excuse me if your description of the awful Canadian system seems pretty good to me.

  20. frizzante says:

    Might as well add the failures of Universal Health Coverage in MA given the debate – here is the link to the NY Times article:

    [www.nytimes.com]

    It is a complicated subject but there is no doubt that the private market based system is failing because they do not follow the law in terms of providing insurance to cover for fair and reasonable care (as above). However, given the efficiency of Meidcare and Medicaid as well as the overall bloat of the US Gov’t, let us not all assume that it would be a wonderful Nirvana.

    I thankfully do not use Blue Cross and am fortunate to have a PPO and still have minor issues with billings, espacially with the arbitrary settings for off-network charges.

  21. ashmantle says:

    First off, I live in Norway, and as many of you know, we have socialized health care.

    Everytime I hear about the American health care system, I feel so bad for you people. We can go to the doctor anytime we want, and we only have to pay a small fee of $20 for our appointments. If we can’t pay, our social care system will take care of the bill for us.
    If we’re in dire need of medical attention, like if we’re having a heart attack or major hemorages or anything, an ambulance will come and get us for emergency treatment at the hospital. Say the treatment takes 2 weeks of laying in a hospital bed, constantly monitored and cared for. When you’re well, you’re released and you don’t have to worry about paying anything, just go home and continue with your life.

    We don’t have any medical insurance for normal human conditions like this, because the state will take care of it for you. However, we have insurance for everything else, and just like in the US, we often have to struggle to get any payment from them, even if we have the right on our side.

    My uncle just had a heart transplant done, and there was major complications. His new heart didn’t want to start beating, but they managed to keep him alive with machines and in an induced coma. Now, after 3 weeks of specialist care, he’s getting better and won’t have to pay anything for the care he’s recieved.

    As for our equipment and doctors, they’re among the best in the western world, often getting paid to go to the US and other countries to learn about new special procedures or medical breakthroughs.

    For all our goods and services in Norway, I have to pay around 25% of my income to the state, but if I don’t earn enough to meet the low-income limit, I don’t pay at all.
    For some reason, I think this is a good solution, since I know that I will be taken care of if something happens.

  22. bohemian says:

    @thecoreyt: You work at Unum? I don’t know if I should feel sorry for you or tell you what cliff to jump off of. They make Anthem look reasonable.

  23. bohemian says:

    The comparisons with Canadian and any potential US programs is a bit off. The Canadian system runs the health care itself. The US proposed systems only run the insurance, not the actual care. That would still be provided by the private providers.

    I can say from experience. If you have no health insurance and can’t obtain health care, that VA system looks pretty darn good.

  24. ivanthemute says:

    @landsnark: Quote: First, we already have a successful government-run system in America (the VA system) and the government run system is much, much more efficient and well-run than the for-profit system that most of us are forced to use.

    My guess is you aren’t a veteran and you’ve never actually recieved care in a VA hospital. I spent eight years in the Air Force, and have the option of going with ‘free’ care through the VA. Oh hells no. Instead, I get my Empire BC/BS through my employer and am fairly happy with it.

  25. mammalpants says:

    anthem was “kind enough.” EFFING BULLS!!T!!!!!!

  26. timmus says:

    I get my Empire BC/BS through my employer and am fairly happy with it.

    Have you had to use it for anything serious? Just asking.

  27. landsnark says:

    @ivanthemute: You are right, I’m not a veteran and have never used the VA.

    But, you are in the minority, most people like the VA system better:
    [ajm.sagepub.com]
    [www.govexec.com]

    And, even if the VA system wasn’t better, I’d take it in a heartbeat since it beats being uninsured and assuming all the risk myself.

  28. failurate says:

    The system sucks. The payer and payee are both motivated to keep prices as high as possible. The customer is denied access to pricing until after service is provided.
    Prices are inflated even higher since doctors practice CYA medicine (that leads to bill padding) instead of being efficient.

  29. missdona says:

    @mammalpants: Total bullshit.

  30. ivanthemute says:

    @timmus: Only ‘major’ items were an accident two years ago in which I broke both legs. The ER visit was covered with no questions by BC/BS. They got a little iffy about scheduling the two mandatory sessions of PT afterward, so I contacted the VA to schedule the same sessions. No fee, no trouble…if I was willing to wait three and a half months after the casts came off for my first session. So I paid out of pocket, and BC/BS reimbursed me (albiet, almost 90 days later,) but still before the VA would have had me in for the work at all.

  31. matto says:

    I am in the middle of a battle with Blue Cross right now, to cover the prescriptions that my neurologist has written me. So far in a month or so, I am about $3000 out-of-pocket on medicine that BC has refused to cover.

    They have decided that I require too much of the medicine. For example, one prescription is for medicine I needed to take several times a day, or endure blinding, crippling headaches. Blue Cross decided that they’d only cover four per month.

    I can only wonder what they would do were I to say that their premium limit has been exceeded, and they only get paid two months per year.

    Blue Cross/Blue Shield operate on fraud and are legalized organized crime. It’s too bad that they seem to have paid off every elected official with the power to put them in jail. But hey, I guess thats the American Way.

  32. matto says:

    Oh PS Ben, I’d love to forward you the correspondence if you’d like to make a story out of it. Especially once I get the inevitable denial of coverage form letter.

  33. thecoreyt says:

    @bohemian:

    Ouch! I have nothing to do with accepting or denying claims.

  34. JiminyChristmas says:

    I have to wonder if Anthem didn’t f*&k themselves by denying coverage of the after-care facility. If the patient’s doctor kept him in the hospital an extra day for an emergency appeal, what did the extra day cost? It could easily have been a couple thousand dollars. Add that to what Anthem paid for the visiting nurse and it may have been just as well to send the patient to the facility.

    BTW, I just love how an insurance company can determine, without ever laying eyes on you and in contravention of your doctor’s recommendations, one is “too healthy” for a particular treatment. Example #238024354 of insurance companies practicing medicine without a license.

  35. missdona says:

    @JiminyChristmas: The not-yet-adjusted hospital bill was over $88K. So let’s do the math…

  36. missdona says:

    @missdona: sorry, for 6 days in the hospital.

  37. ivanthemute says:

    @landsnark: Quote:And, even if the VA system wasn’t better, I’d take it in a heartbeat since it beats being uninsured and assuming all the risk myself.

    Agreed. Something is better than nothing, but the VA is just a shred cheaper than most doc-in-a-box places.

  38. TheElectricMonk says:

    I used to work for an insurance company. Retroactives are used to cover services already rendered. If he had gotten the treatment when originally planned this would have saved his wallet, probably didnt specify in the appeal that he was awaiting approval to begin treatment. In most cases involving the heart(it being so important) treatment is administered during the appeal. Shame I wasnt his agent.

  39. 00exmachina says:

    @ashmantle:
    Norway’s population 4,627,926
    United States population 301,139,947

    Norway’s system won’t work in the US simply because of a matter of scale. Norway being the smaller country in both size and population allows it to use systems that would simply be too cumbersome or administration intensive for other countries.

    There is no panacea solution for how to handle health care, and just because a system works in one country does not mean it will work somewhere else unless all of the other veriable in play are the same as well.

  40. missdona says:

    @00exmachina: Not to mention some of us already pay 25%++ to the government and don’t get any sort of social benefits.

  41. landsnark says:

    @00exmachina: On the contrary – the greater the population, the more money you save on fixed administrative costs. If Norway doubled in population, their system would become more cost-effective per person, not less cost-effective, because the fixed costs would be spread out over more taxpayers.

    As I pointed out above, Norway’s type of system is already up and working in the States in the form of the VA system, and it is more efficient and has greater patient satisfaction than the U.S. for-profit system.

  42. etherealclarity says:

    Let’s not forget… part of what makes healthcare so lousy in this country is the tax code that ties it to employment. If we were free to shop around for health insurance and healthcare, it wouldn’t be so lousy. Competition and all that.

  43. 00exmachina says:

    @landsnark:
    The administrative costs are not fixed, it is a fixed amount per person. Which is drastically different. Also you missed the point of mentioning the populations, there are how many people served by the VA system?
    I’m betting it is a lot less then even the population of Norway.
    It’s the economics of scale ([en.wikipedia.org])
    You’re shooting for the low point at the middle of the graph,
    Smaller groups like the VA, are more able to hit this point because thee is less inherent administrative costs.

    When you scale it up you wind up not just picking up the administrative expenses generated by the individual in the health care system, you also pick up non productive administrative expenses of having to pay for people to keep all of the administrative items organized. Socialized health care won’t get rid of forms, or data that needs to be tracked and accessed, thats where the bulk of the administrative expense comes from.

    The privatized health care system in place in the US currently was an attempt to use scale to hit that optimal point, because it allowed the private companies to serve smaller subsets of the total us population, just at the VA does in your example. Plus per the study conducted in 1998 on the VA points to a less then stellar ability to take care of patients ([archinte.ama-assn.org])
    (I would have used a more recent study but could not find one published.)
    Granted the study only looks at outpatient treatment, but that is who the bulk of VA patients are treated.

  44. landsnark says:

    @00exmachina:
    “The administrative costs are not fixed, it is a fixed amount per person”

    Medical administration, like all business endeavors, has fixed costs:
    [en.wikipedia.org]
    and the per capita costs go down as the population covered goes up.

    “Socialized health care won’t get rid of forms, or data that needs to be tracked and accessed, thats where the bulk of the administrative expense comes from.”

    I think you have this exactly backwards. Endless paperwork is exactly the problem with our current for-profit system, caused by the patchwork of insurance feifdoms that do not share records or cooperate with each other or health care consumers. And, of course, this is being too generous – these insurance companies also add still more paperwork to delay/deny treatment (as the OP can attest).

    This administrative BS consumes 31% of our health care dollars. By contrast, Canada’s single payer system spends about 16% on their health care dollars on administration.

    This inefficiency in our system is a huge waste of time, money and lives.

    “Plus per the study conducted in 1998 on the VA points to a less then stellar ability to take care of patients ([archinte.ama-assn.org]) (I would have used a more recent study but could not find one published.)”

    Let me help you then. Here are several more recent studies that show that VA clients seem to be very happy, especially compared to the rest of us poor slobs:
    [ajm.sagepub.com]
    [www.govexec.com]
    [www.defenselink.mil]

    And – let me complain about this one more time – as an uninsured American, I wish I had even an inefficiency administration to complain about – right now it’s just me and a very small savings account.