Friday, June 02, 2006

R&C Sucks

One always hesitates to bitch about their insurance coverage when all they have to do is look around themselves and listen to the horror stories of those without any coverage at all. If you change your point of view, you find your own situation not so intolerable. I’m one of the very, very lucky ones and I thank God and my late husband for that.

When one is an ExxonMobil widow the sloop becomes increasingly slippery. I'm beginning to get the idea that maybe ExxonMobil's health insurance provider, Aetna, has decided I've lived too long. They are killing me with their nit picking of all my recent medical necessities.

My cardiologist, who I consider my primary care physician, is no longer In-Network. I don't know why. As the patient, I don't really want to know job is to take my meds and try and follow his directives. He's being very generous with his billing to me and his level of care and concern has not diminished one whit, to wit I am extremely grateful. The Dog and Cat Animal Hospital he participates in, aka Cy-Fair Medical Center, is In-Network, but it seems their ER doctor isn't. If one is taken by ambulance to the D&C Animal Hospital, woe is you when the determinations of benefits come down from Mt. Sinai located near Mt. Aetna.

The rub seems to be what is considered "Reasonable and Customary" or R&C as those in the trade like to refer to it. R&C could also stand for "Rape and Crush", but that's another story for another blog. How am I, a mere mortal, supposed to know in advance what's reasonable and customary, you ask. By a pre-determination of benefits, so says the booklet chocked full of such gems of wisdom for the insured as:

Reasonable and Customary Limits
Allowable amounts for services are determined by reasonable and customary (R&C) limits. Aetna uses the industry-wide standard for R&C limits obtained from the Prevailing Healthcare Charges System (PHCS). R&C limits are based on data from several surrounding regions rather than one specific zip code. R&C limits apply ONLY TO NON-NETWORK PROVIDERS AND SERVICES. R&C for services are set at the 90th percentile of the range of charges for a particular procedure generally in the same geographic area(s).

So, work with me here, by choosing to remain with the physician that saved my life 9 years ago and knows me like a book, inside and out, including all the turned down pages, all of the sudden R&C charges are coming out of my butt! Their solution would be to dump my doctor and follow Aetna's party line?

I've got to play one race card here so bear with me. The doctors that are given the Aetna seal of approval almost all have foreign names. Is that just a coincidence? Am I being unfairly bigoted? Did I just lose both your sympathy and your support with this tacky observation?

I could fight this thing tooth and nail. I could hire an attorney and end up spending more money than they say I owe. I could beg and plead for a break. I could just pay the money owed and shut up. Right now I'm just venting to clear my head and get my emotional ducks in a row so that WHEN I do call them I don't resort to scathing retorts and ultimately blubber like a baby who's just dropped her pacifier.

If I live long enough, I'll be eligible for Medicare in 667 days (good thing I wrote this today!!), then I’m sure a whole new set of insurance concerns will concern me. It just seems MEAN to me that it was an EMERGENCY and through no fault of my own, they are slinging dollar signs my way.

I’m happy I have this blog to vent in because I can’t find anything connected to ExxonMobil’s retirees/survivors that offers any kind of advice or place to commiserate. They just want you to contribute to the United Fund, etc. One has to get it out, it’s good mental health, and Lord only knows what kind of R&C shit I’d be swimming in if I had a nervous breakdown!


I just got off the phone with a lady that works for the billing people for the ER doctor and she gave me a fax number to use to try and get him/them to accept the assigned insurance benefits plus my 20% and forgive the rest. Keeping my fingers crossed…. I wonder if the ambulance folks are in a forgiving mood?

1 comment:

Anonymous said...

Welcome to modern healthcare! It's almost a miracle that you've been able to keep your doctor so long, the "HMO Shuffle" has been bouncing them out of plans for decades now. The ones that stay inside the plans do seem to be disproportionately from India or other countries originally and most of those who leave the plans have a variety of things to say about the subject.

To be fair, most people want $1000 of healthcare and only pay $5 but it has long been a numbers game and will continue getting worse. The system is not equipped to provide everyone with optimal care and even basic care drives up the cost for those of us who pay (via our healthcare provider and our taxes). There are no free rides and it's a shame that your doctor isn't on your plan anymore.

The upside is that with all that loot you made in the garage sale recently, you can afford keeping him longer than most. Yay you! ;)