Another Insurance adventure.....and a easy way to document your adventures!!!

[Vladimir]

I had a new doctor appointment in late September, and had him do a quick prescription for blood pressure medicine until my physical in November.

In November, I had a huge spike in my blood pressure which resulted in taking many more pills as well as two visits to the emergency room for extremely high blood pressure.

My doctor then wrote ANOTHER prescription for my blood pressure medicine ($1.87 with insurance, $20 without).  When I went to pick up my medicine, the pharmacist said the insurance company DENIED the prescription.  Given my previous adventures with GEHA insurance, I just rolled my eyes and the pharmacist said you can buy it out of pocket for $20.

As I was leaving I asked for a copy of the form denying the prescription.

This morning I called the number on the denial claim form.  On the form there was the Molina Insurance Company of Washington which denied my claim.  I had no clue who they were, but assumed that they were a contractor for GEHA.

Called them.  They administer the Medicaid program for the state of Washington.  I am NOT a Medicaid client, nor have I had ANY business connections ever with the insurance company.  They confirmed that I was NOT a client of theirs.

I asked why they denied my claim, instead of sending a note to the pharmacist that I was not their client and to contact MY insurance company.  They refused to answer.

What was worse, is when I asked the pharmacist why he accepted the denial.  He said ALL insurance companies are the SAME. 

It doesn't matter who they send the prescription to review!!!

They DID have a copy of my previous prescription information and made the denial on that basis!!!

I followed that phone call with a call to the Washington State Insurance Commissioner and pointed out that they were going to KILL people depending on the prescriptions that they were denying.  They agreed, and are assigning a case number and a investigator to follow up on my denial of the prescription.

ANYWAY, after my last adventure with GEHA and taking copious notes I decided this time to RECORD my conversation with the insurance company.  All it takes is a phone and another phone or IPAD with a voice memo function.  Put your phone on speaker and record on the second phone or IPAD.

Full instructions here:  https://www.zdnet.com/article/how-to-record-a-call-on-iphone/.

In many states, YOU MUST INFORM them that you are recording the conversation.  I start with stating the number I am calling and then start the conversation with the fact I am recording the conversation and Washington state is a two party disclosure state for recording conversations. 

It made the call so much easier.  I could focus solely on my questions and answers instead of stopping to take copious notes.  It did make the people on the other end, slightly more courteous when they realized they were being recorded.  But the Molina Insurance guy did say "your not our client and I have nothing further to say" and then hung up on me.

The Washington state Insurance Commissioner guy was impressed that I recorded the conversation and gave them the required legal warning.

I intend to use this in ALL my future conversations regarding insurance, etc. etc. etc.

[2gypsies]

What did your doctor say about the sudden spike in blood pressure?  Did you have and scans to see what the issue is?  Please don't let it go as it could be serious.

[Kirk W]

Not being familiar with GEHA, I did an online search and found this.

Plans are offered by GEHA and insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract. Enrollment in the plan depends on the plan's contract renewal with Medicare. Benefits, features and/or devices vary by plan/area.

[Vladimir]

12 hours ago, 2gypsies said:

What did your doctor say about the sudden spike in blood pressure?  Did you have and scans to see what the issue is?  Please don't let it go as it could be serious.

I didn't let it go.

But I was/am more concerned than the doctors.  I ended up with two consecutive visits to the emergency room and four doctor visits in the space of two weeks.

I did have a CAT scan, it was negative.   My blood pressure crossed 180/140 which is the threshold to go to the emergency room.  Still do not know what caused the spike, but nobody seems concerned about that!!! 

Today, my blood pressure was 111/86 with a pulse of 68.  I did get a new drug to lower my heart rate.

The injury started as a pickleball injury, with real significant pain.  The initial treatment include a high dose of NSAID drug for pain, which I think started the increase in blood pressure.  Then I quit taking it and the doctors assured me that it would flush out my system in three days.  After three days quitting the NSAID  I went to the emergency room with the sky high blood pressure.

I also picked up a splitting headache that was directly correlated with blood pressure.  I actually had a good idea of my blood pressure simply by the type of headache I had.  The emergency room doctor gave me a shot and tylenol for the headache and it went away almost immediately.  If I had migraine headaches I would definitely look into the shot.

I suspect it was the NSAID that spiked it, but the doctors disagree. 

I did get a hydro-condone drug for the pain, and a note from GEHA that they were giving me the drug ONLY because my doctor insisted on it!!! 

Like I said an adventure.  I didn't realize my 70's were going to be this much fun!!!

Thanks for your concern.

 

[Vladimir]

4 hours ago, Kirk W said:

Not being familiar with GEHA, I did an online search and found this.

Plans are offered by GEHA and insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract. Enrollment in the plan depends on the plan's contract renewal with Medicare. Benefits, features and/or devices vary by plan/area.

GEHA has been my insurance company for over 20 years.  It is the SAME insurance that I had when I was working with the same premiums and benefits.  It addition I also carry Medicare Parts A and B.  I think I am well insured to the say the least.

The troubles with GEHA started as soon as I qualified for Medicare.  BTW, I am one of the few people that actually READ and looked at the health insurance contract all 120 pages of it!!!  I really think the insurance companies are running scams with Medicare and dragging their Medicare eligible customers into paying EXTRA for already covered services.

I did drop my fraud case with the Attorney General Fraud Division in Washington state once the No Surprises Act passed and suddenly GEHA paid for a regular physical just like promised on Page 38 of the health insurance contract.

Here are my previous threads for those interested:

https://www.rvnetwork.com/topic/144561-medicare-annual-exam-and-federal-employees-health-benefits-coverageplease-read/

https://www.rvnetwork.com/topic/146640-no-surprises-actevery-rver-needs-to-understand-this-new-law/

The insurance companies are denying claims automatically and then approving the claim once you appeal.  They are betting that you will just pay the claim rather than appealing the ruling.  According to the article ONLY 0.2% of people appealed the claims with the insurance company.  It is a great money maker for the insurance companies.

That is what the insurance company and the fraud division of the Federal Inspector General's Office told me.  Appeal it!!!  I told the Inspector General's Office I reporting suspected fraud and have pretty good evidence.  I want to stop the fraud.  The $51 dollars is chump change compared to what their stealing from the American people!!!  They refused to take the case unless I appealed.  Which led me to the Attorney General's office. 

They are working on repealing the No Surprises Act.

Read this article for how it works: https://www.healthcaredive.com/news/cigna-lawsuit-algorithm-claims-denials-california/688857/

Other insurance companies than CIGNA are involved in the practice.

As noted in the article:

The report triggered an ongoing investigation by the House Energy and Commerce Committee, along with state and federal regulators.

Here is the membership of the House Energy and Commerce Committee.  If you have a Congressional representative on the list, it might be wise to send a note telling them to fix the "fraud" NOW.

https://energycommerce.house.gov/representatives

 

 

 

[Kirk W]

Here are some links to articles that I have read which may be related to your difficulties. I have no direct experience with any "Advantage" plan as we have original Medicare and a part G supplement, the cost of which is reimbursed by an HRA from my previous employer. 

Medicare Advantage Is a Massive Scam   BY RYAN COOPER, APRIL 29, 2022

'Deny, deny, deny': By rejecting claims, Medicare Advantage plans threaten rural hospitals and patients, say CEOs   By Gretchen Morgenson, Oct. 31, 2023

Is Medicare supplemental insurance worth it?   BY MATT RICHARDSON, SEPTEMBER 15, 2023

Medicare Advantage increasingly popular with seniors—but not hospitals and doctors  BYJULIE APPLEBY AND KAISER HEALTH NEWS, November 30, 2023 

The pros and cons of Medicare Advantage plans    BYRICHARD EISENBERG, August 9, 2023

[Vladimir]

We don't have a Medicare advantage plan.

GEHA is our regular medical plan that we had for 20 years and still carry in retirement.

[sandsys]

1 hour ago, Vladimir said:

The insurance companies are denying claims automatically and then approving the claim once you appeal.  They are betting that you will just pay the claim rather than appealing the ruling.  According to the article ONLY 0.2% of people appealed the claims with the insurance company.  It is a great money maker for the insurance companies.

There's a movie about that practice in which the claimant died during the time between the claim was made then finally paid. I wish I could remember the name of it. I thought the exposure made during that movie would have stopped the practice but, apparently, not.

Linda

[2gypsies]

4 hours ago, Vladimir said:

Thanks for your concern.

 

I'm glad you're OK now but if it happens again get yourself to the ER.   I don't want to alarm you but a dear acquaintance had the exact same issues with very sudden overly high BP and excruciating headache and he had a cerebral hemorrhage and hasn't been the same since.  😞 His BP was always normal.  Years ago there was a big push on taking a daily baby aspirin to prevent a heart attack.  He took one daily for years and docs attributed it to weakening a blood vessel and he had a brain bleed.  Sorry... I don't want to alarm you but it just struck a nerve of remembrance.

[lappir]

4 hours ago, sandsys said:

There's a movie about that practice in which the claimant died during the time between the claim was made then finally paid. I wish I could remember the name of it. I thought the exposure made during that movie would have stopped the practice but, apparently, not.

Linda

Linda, 

Movies are for entertainment, not really depicting real life....

The sad part is, most stories do have real life as the starting point. Someone sees something and writes about it, next there is script using made up people and places so no one really knows if it really happened or not. Another thing is the films about the future and what people think could never happen. Well in my mind if someone has thought up the scenario, made it happen in a film, then someone else cant tweak it a bit and make it happen in real life. 

Wouldn't it be wonderful if all the bad things that happened in movies never happened in real life. How about all the good things that happen  to people in real life that we hardly ever hear about. We certainly hear about the majority of the bad stuff. 

I'm reading a book I found in the dumpster last week called "The Greatest Gamblers" it was written by Ruth Sheldon Knowles about the "Epic of American Oil Exploration" it appears in 1959, but a second edition came out in 1978. Some of the stuff that was done during those early times was horrendous and I want and don't want to see the movie of the awful crimes done to the Native Americans in the Tulsa area. Yet have we learned? Not at all it appears to me, at least not the majority yet. 

 

Rod

[Ray,IN]

I'm happy you're getting things straightened out. I too had very high BP after the heart attack, the highest reading was 210/140. My cardiologist did open heart surgery, then the next year 2 long stents. I'm still on 2 BP meds, but now have the opposite problem, low BP and low heart rate; BP is 117/50 pulse has been as low as 42, so he halved one BP med and now considering stopping that drug entirely.

My point is follow the Dr. directions exactly, that's why we pay them the big bucks.

[Vladimir]

On 11/30/2023 at 3:43 PM, 2gypsies said:

I'm glad you're OK now but if it happens again get yourself to the ER.   I don't want to alarm you but a dear acquaintance had the exact same issues with very sudden overly high BP and excruciating headache and he had a cerebral hemorrhage and hasn't been the same since.  😞 His BP was always normal.  Years ago there was a big push on taking a daily baby aspirin to prevent a heart attack.  He took one daily for years and docs attributed it to weakening a blood vessel and he had a brain bleed.  Sorry... I don't want to alarm you but it just struck a nerve of remembrance.

 

On 11/30/2023 at 6:33 PM, Ray,IN said:

I'm happy you're getting things straightened out. I too had very high BP after the heart attack, the highest reading was 210/140. My cardiologist did open heart surgery, then the next year 2 long stents. I'm still on 2 BP meds, but now have the opposite problem, low BP and low heart rate; BP is 117/50 pulse has been as low as 42, so he halved one BP med and now considering stopping that drug entirely.

My point is follow the Dr. directions exactly, that's why we pay them the big bucks.

Thanks for the concern.

Went to my final follow up appointment yesterday.  My blood pressure is finally down, and the doctor also added a drug to lower my daytime heart rate.  That was new and different.  I have always had a high heart rate, except when sleeping.

I did get "instructions" on how to deal with lowering blood pressure and pulse in the future.  Mine is directly correlated to weight.  5 lbs loss/gain is equal to 5 mg of Lisinipril.

The thing I did NOT get was an answer on what happened.  Nobody seems concerned about that.  Every doctor seems to think, we fixed it!!  Yeah, lets move on. 

Is there a difference between a shade tree mechanic and a shade tree doctor??   I feel like somebody banged on the side of me and the blood pressure went down as a result and the doctors all said "we fixed it".

I still think it is somewhat related to the Nsaid pain killer that I was given.  Done with those.

Not a good year 2023.  

[Ray,IN]

I agree, there are differences in doctors and their treatment methods. I suggest if you are not satisfied with your present doctor, look around and get a 2nd opinion. 

I too lost about 5#, resulting in the heart Dr. taking me off all my BP and pulse meds because the numbers fell too low; BP is now 117/58, pulse 72 after being off heart meds for a month now.

I've changed how I eat so much I'm almost a vegetarian now, and take fish oil caps 3x a day per an internist Dr.

Hang in there.

 

[Vladimir]

7 hours ago, Ray,IN said:

I agree, there are differences in doctors and their treatment methods. I suggest if you are not satisfied with your present doctor, look around and get a 2nd opinion. .....

I actually got FOUR opinions.  Continuity of care might have been an issue. 

I did find a emergency room doctor that was really good.

We will see how my new doctor turns out.  He graduated from the University of Moscow.  NOT the University of Idaho at Moscow, but the other one 12 times zones out.

He was on vacation so I called his nurse, for a trigger that would mean me going to the ER.  That worked, as I ended up in the ER that night.

The first question his nurse had was "she talking to Vladimir" since he had so many Russian speakers and she thought I was the translator.

I told her in my 20's even with a name like Vladimir everybody expected me to speak English.  Now that I am in my 70's with a name like Vladimir everybody assumes I do NOT speak English.

[Kirk W]

Reading through the comments related to high blood pressure makes me wonder about the age groups that we are discussing. At my first visit to my primary care physician after turning 80, she scheduled me to see a cardiologist, mostly because I had never been to one. I am fortunate to have come from parents who descended from a long line heart healthy ancestors. As a result my typical B/P is 112/68, which I'm told is unusual for someone my age.  🙄

[Vladimir]

On 11/29/2023 at 4:49 PM, Vladimir said:

My doctor then wrote ANOTHER prescription for my blood pressure medicine ($1.87 with insurance, $20 without).  When I went to pick up my medicine, the pharmacist said the insurance company DENIED the prescription.  Given my previous adventures with GEHA insurance, I just rolled my eyes and the pharmacist said you can buy it out of pocket for $20.

As I was leaving I asked for a copy of the form denying the prescription.

This morning I called the number on the denial claim form.  On the form there was the Molina Insurance Company of Washington which denied my claim.  I had no clue who they were, but assumed that they were a contractor for GEHA.

Called them.  They administer the Medicaid program for the state of Washington.  I am NOT a Medicaid client, nor have I had ANY business connections ever with the insurance company.  They confirmed that I was NOT a client of theirs.

I asked why they denied my claim, instead of sending a note to the pharmacist that I was not their client and to contact MY insurance company.  They refused to answer.

What was worse, is when I asked the pharmacist why he accepted the denial.  He said ALL insurance companies are the SAME. 

It doesn't matter who they send the prescription to review!!!......................

 

Can you quote yourself and then answer!!!

Anyway, more information on Molina HealthCare of Washington and their business practices.  I don't understand the fine, WHY IS THIS COMPANY STILL IN BUSINESS???

https://www.yoursourceone.com/columbia_basin/wa-fines-molina-healthcare-100-000-for-enrollment-and-billing-errors/article_b855bb32-e16e-11ee-b01d-8bd95a5974d0.html

 

[Chalkie]

17 hours ago, Vladimir said:

Can you quote yourself and then answer!!!

Anyway, more information on Molina HealthCare of Washington and their business practices.  I don't understand the fine, WHY IS THIS COMPANY STILL IN BUSINESS???

https://www.yoursourceone.com/columbia_basin/wa-fines-molina-healthcare-100-000-for-enrollment-and-billing-errors/article_b855bb32-e16e-11ee-b01d-8bd95a5974d0.html

 

What's missing in that article is how many people are in their system. 2000 of say 200,000 is only 1%. While we could hope for 0% I think we all know that is not going to happen.

[Vladimir]

2 hours ago, Chalkie said:

What's missing in that article is how many people are in their system. 2000 of say 200,000 is only 1%. While we could hope for 0% I think we all know that is not going to happen.

There was a Wall Street Journal article on insurance fraud by the INSURANCE COMPANIES against their customers.

Atena had ONE doctor overseeing and accepting or denying claims from their clients.  I am not sure how many Dr. Atena has reviewing claims.  That one Dr. DENIED 600,000 insurance claims in one year!!  Excluding vacations and holidays, that ONE Dr. denied a claim every FIVE SECONDS for while he was on the clock.  That does not include the insurance claims he approved!!!

The Wall Street Journal article noted that ZERO POINT FIVE percent of Atena clients appealed their denial of coverage.  That one Dr. made Atena millions and millions of dollars in insurance claims that they did NOT have to pay.

So it is with Molina.  If less than one percent complained, the number of clients and non-clients (like me) the Molina defrauded is a really high number.

When I filed my complaint with the Inspector General for health care fraud, he told me to appeal with GEHA and they would refund my $51 dollars.  This for what looked a well designed fraud system that was defrauding the taxpayers and Federal employees for probably millions of dollars.

We really need a Congressional investigation into health care insurance fraud by the INSURANCE companies.

The other angle I would like to see investigated is the targeting of people by the insurance companies that cannot speak English.

My parents did not speak English.  I translated for them as a kid and I was amazed at the number of frauds that they were invited to participate in!!!  I did give me a early understanding of how many people out there can rob you with a fountain pen.

These days, I have had several insurance companies and medical offices when I call them ASK if I am translating for the person making the complaint.  There is always a sense of surprise at the other end when I tell them "no, that is me.  I speak perfect English.

 

[Chalkie]

1 hour ago, Vladimir said:

There was a Wall Street Journal article on insurance fraud by the INSURANCE COMPANIES against their customers.

...

We really need a Congressional investigation into health care insurance fraud by the INSURANCE companies.

The other angle I would like to see investigated is the targeting of people by the insurance companies that cannot speak English.

...

 

This is interesting as it ties to the thread started by lappir. My cousin, a nurse, just posted a link on FB that goes along with this as well.

Are Regulators Finally Waking Up to the Threat That Is UnitedHealth Group?

[Vladimir]

Thanks for posting the link.

I have insurance through GEHA??

NOPE.

Last year Aetna administered the GEHA program.  This year it moves to United Health Care.  GEHA is just skimming the policy premiums and government payments.

The entire system is corrupt. 

Where is Teddy Roosevelt when you need him??

[Kirk W]

Thanks for sharing that, Chalkie! I just posted it on my Facebook page too. 

[Randyretired]

United Health Care's dominate position is worrisome.   However, they can if they want to provide some excellent insurance.  We have an employer provided UHC Medicare Advantage Plan we have loved it.  My DW would not be an insurers delight yet they have never been a problem.  I asked for a change in my DW's treatment and the doctor said that would be a good plan but some insurances may not approve.  They sent it in and before we got home it was approved without limitations.  This has been typical of our plan.  Never have we been denied.  Optum is our drug plan and a couple of times they screwed up when we are traveling but they generally made it right.  No problems when home and the prices are good.  I hate to see them so dominate but the verticle integration does work.  As the government intervenes I hope all of good can be saved and the lack of competition can be controlled.

[Vladimir]

2 hours ago, Randyretired said:

United Health Care's dominate position is worrisome.   However, they can if they want to provide some excellent insurance.....................

John Wesley Harding and Bonnie and Clyde had lots of fans. 

They were upstanding people when it came to the lower classes.

Somehow, I suspect United HealthCare doesn't share the same values as Harding and Bonnie and Clyde.

In my case, the taxpayers are picking up my Medicare and insurance costs.  They are ripping off the taxpayers. 

I sent a copy of the 'insurance contract" between the Federal government and GEHA.  Page 38....GEHA will pay for a yearly physical WITHOUT co-pays.

They just went ahead and charged my visit as NOT a physical and for good measure coded my visit out of network!!!

Trump's approval of the NO SURPRISES MEDICAL ACT took care of the "out of network" scam.  They, however, refuse to list my annual physical as a physical.  They even went as far to REFUSE to tell me what the codes were on my billing as to the medical services I received!!

How can I correct a wrong billing...if GEHA will not tell me what I was BILLED for in terms of medical services.

[Randyretired]

As I posted UHC can provide decent insurance if they want to.  I can't comment on your situation other than UHC's dominate position has the potential  to be a problem.  Our MA plan says the same thing for no cost to us for all of our primary care including physicals.  One time I was billed $10.  I called and the doctors office insisted it was correct so I called UHC with contact information.  The doctors office called back and said there was a billing error and the $10 was removed.  I have heard a number of complaints about MA and I think there may need to be some government intervention but I am also skeptical about the government's ability to bring about good outcomes.

[Vladimir]

32 minutes ago, Randyretired said:

As I posted UHC can provide decent insurance if they want to.  I can't comment on your situation other than UHC's dominate position has the potential  to be a problem.  Our MA plan says the same thing for no cost to us for all of our primary care including physicals.  One time I was billed $10.  I called and the doctors office insisted it was correct so I called UHC with contact information.  The doctors office called back and said there was a billing error and the $10 was removed.  I have heard a number of complaints about MA and I think there may need to be some government intervention but I am also skeptical about the government's ability to bring about good outcomes.

I hear you, BUT there is no recourse except government to bring about fair outcomes when your dealing with insurance companies that will not HONOR or ABIDE the contracts they signed with the Federal government.

Except, these days in the immortal words of Bob Brinker "we have the best government money can buy".