The Serpentine World of Health Insurance

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Being of a certain age, and with a family history of colon cancer, my doctor browbeat me into undergoing a colonoscopy in late April. This occurred three years before the warranty expired on the last one. Actually, the procedure is not a big deal. The prep, however, is not a stroll in the park. In fact, there is only one location to which you will be strolling. Likely, you will walk briskly.

I am certain many of you reading this know this. For most of you under the age of 50, you will find out soon enough. That is not the point of this story. It is what happened after that boggles me, and makes me wonder if we will ever get a health care system that makes sense.

I have retiree health insurance through my former longtime employer. In order to keep costs down, this year the company — which is self-insured but uses a large health insurance company to administer the plan — quit paying for preventive procedures, like physicals and mammograms. I would have known this if I had read the brochure sent me last November, but I didn’t. So as the bills came in from the various health-care providers involved in this procedure — the gastroenterologist, anesthesiologist, the day-surgery clinic and a medicine man from Papua Guinea — I happily chunked the bills into recycling. In a few weeks, my insurance would pay up, and then I would have to cover a small portion as co-pay. That is how it has worked in the past.

After the third round of bills, and a few collection letters, I called the insurance company. That is when I found out preventive procedures were no longer covered. But this was not preventive. The doctor badgered me into undergoing a colonoscopy because of family history. Nobody volunteers for this procedure, I argued. OK, the customer rep told me. Tell all the providers to change the coding to family history, and it will be covered.

Coding is critical to whether a procedure is covered, and how much money the provider receives. As of Oct. 1, a new coding system was adopted under the Affordable Care Act. The ICD-10 system replaces ICD-9. Now, instead of 13,000 different codes, providers have 68,000 billing codes from which to choose. This increases by five-fold the odds that a code will be used that is not covered under my plan — or yours.

I started with the billing office of the doctor who performed the procedure. I was assured the code would be changed, and that the message would be passed down the line to the others involved. Just in case, I called several of the other providers as well to advise them to change the code.

Several weeks passed, nearly each day’s mail bringing new bills with increasingly unfriendly messages. I realized that my health insurance provider had not sent a single email announcing a claim was being processed. I was going to be on the hook for several thousand dollars if this was not fixed.

I emailed my former employer’s benefits office pleading for help. And, indeed, they sprung into action. A nice lady called me and said she was having her assistant personally contact everyone involved to make sure they coded it correctly. And, she added, this happens all the time. The doctor’s office did refile but used the same code! So it was rejected again.

The only choice I have is to trust my former company can get these folks to do what I was not able to do on my own. It is nice to have someone on your side who understands this byzantine system, willing to wade through the morass of providers, billing codes, and accounting systems to straighten this out. But what about the average person out there who doesn’t have these resources? There has to be a simpler way.

Don’t blame Obamacare. The system was broken long before the ACA became law.

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 In Googling for this piece to learn more about coding, I came across a piece in HealthcareDIVE (healthcaredive.com) that I must share. It listed the 16 most-absurd codes under the new ICD-10 system. Here are a few of them:

• Sucked into jet engine, subsequent encounter. It is not what you think: a second incident of being sucked into a jet engine. The “subsequent encounter” means with a doctor. I wonder if this is covered under my plan?
• Swimming pool of prison as the place of occurrence of the external cause. Prisons have swimming pools? Actually, at least one federal prison does. But not in Texas.
• Burn due to water-skis on fire, subsequent encounter. As the writer put it, “How does this happen? Are water skis even flammable?”
• Struck by macaw, initial encounter. So a committee brainstormed codes for every possible mishap. The person who came up with “struck by macaw” possibly lives in Colorado, where imbibing pot is legal.

Go to the HealthcareDIVE site to read more goofy codes. Here’s hoping my colonoscopy does not get recoded as “Other contact with cow, subsequent encounter.”

That probably is not covered, either.

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