11.08.17

The Case Against Health Insurance Companies

PUTTING THE ‘FUN’ IN DYSFUNCTIONAL

As a self-employed independent contractor, I am responsible for providing my own health insurance. Due to the ever-changing landscape of health care, I have had to switch insurance plans each of the past three years. I am now back with Blue Cross Blue Shield of Illinois, with a family HMO plan that costs over $900 monthly. This is my first HMO experience; we picked it because it cost less per month than a PPO. With an HMO, it is imperative to follow the exact HMO guidelines to make sure everything is covered, beginning with the primary care physician.

As an athlete and personal trainer, I am responsible for the health and care of my body. I am fully aware of how my fitness and nutrition choices impact my health. I am also aware that the better care I take of myself, the less likely I am to be ill. So, for the majority of my training career, I have paid for insurance without needing to use it. I am rarely sick, hardly injured, and would self-classify as being in excellent health.

Back in mid-June, I was involved in a judo accident where my right ankle and right knee were rolled up on by a training partner, and my body was bent backward over my trapped joints. Immediately, I heard numerous “popping” sounds followed by instant pain. I feared the worst. My real-time guess was that I blew out my knee and broke my ankle. I painfully hobbled off the mat, did a quick self-check, and tried to “walk it off”. My ankle was pretty swollen, and it hurt to bend my knee. Although it was painful, I could move.

I tried to convince myself that since I was walking, these injuries were minimal, just my body’s response to trauma. I was lucky I could still move. But, I previously put in thousands of body-work hours to protect myself with a balance of strength, flexibility, and mobility. One awkward incident shouldn’t break me, right? Still, there was pain, and a specific event that caused it. I needed to know what was wrong.

That night, I visited Dr. Jason Godo, the chiropractor that has helped educate me more than anyone. I explained how it happened, and showed him the position I was in before being bent over backward. He did some muscle testing, looked at my joints, and gave me his best opinion: severely sprained ankle, and a probable torn meniscus. He wrote me an MRI script, and pointed out that his care was not covered by my HMO. I paid out of pocket, and weighed my options.

Dr. Laura Cayce is another chiropractor that treats me, as she used to treat patients out of On Your Mark Training and Coaching. She has helped me with numerous small problems; more trying to undo the effects of 38-years of body mileage. With her muscle testing, acupuncture, dry needling, and Graston techniques, she had the same diagnosis as Dr. Godo: severely sprained ankle, and a probable torn meniscus. Dr. Cayce wrote me an MRI script, but she also is not covered by my HMO.

As I attempted to schedule the MRI appointments, I was reminded why having an HMO is difficult: BCBS denied my coverage.

Realizing I needed to alter my care process, I followed BCBS’s plan of starting with my PCP through Northwestern Medicine. Dr. Sean Huang evaluated me — also suggesting I have a torn meniscus — and set me on a path that precisely follows the BCBS HMO sequencing: (1) Ankle X-ray at Galter/Feinberg Pavillion (2) Appointment with a Shirley Ryan Ability Lab physical medicine physician (3) Let the healing begin! Dr. Huang explained that while he did not believe my ankle or knee to be broken, the insurance companies have to be told what this injury is not before being told what it is.

So, I followed the plan: got my ankle X-rayed and then set up at Shirley Ryan. Dr. Alexander Sheng checked me out and made the same diagnosis: severe ankle sprain, probable torn meniscus. Dr. Sheng X-Rayed my knee — to follow hospital protocol — while suggesting MRIs for my ankle and knee, to be completed that same evening. While waiting for my MRI appointments, I received a phone call from BCBS telling me coverage for these MRIs has been denied. BCBS explained that the Shirley Ryan Ability Lab is not covered by my HMO; I counter that I have been referred by my HMO-covered PCP. Denied! BCBS said no referral from my PCP meant no clearing me for any out-of-network appointments.

Meanwhile, Dr. Huang swore he submitted all necessary paperwork to BCBS, and everything should be covered and run smoothly. As I waited on the sidelines while BCBS tried to (un)successfully communicate with Northwestern Medicine, I received zero insurance-covered care for my leg. Out of pocket, I still worked with Dr. Cayce once a week for knee and ankle treatment. Neither joint was improving and there was still heavy pain and reduced range of motion. Finally, in late-July — without MRIs — I was approved for physical therapy through Athletico. But, on the walk to my first Athletico appointment — three blocks from my home — I got a call from Athletico informing me that BCBS has not approved any physical therapy.

As my anger reached Hulk-like levels, I called BCBS to understand how in a heartbeat, my physical therapy coverage can transition from covered to not-covered. Throughout this idiotic process, there have been two constants: I have done my job by (1) having insurance and (2) paying my bill every month. Using health insurance should be easy, not fucking impossible. After talking with a few different BCBS phone operators, I finally got one that explained the mix-up: someone at BCBS looked at a previous, expired account and denied me. Expired account equals no coverage. They did not bother to recheck their work and see the current account, which had been active from the beginning of 2017. Human error, and a simple lack of attention, cost me two MRI appointments, six weeks of specified ankle and knee treatment/pain management, and incredible amounts of stress.

My physical therapists, much like Dr. Godo and Dr. Cayce, were not sure how to treat these injuries without proper imaging. Their treatment plan was like grasping at straws in the wind; we were hoping to catch something. We tried to guess what could be happening, instead of knowing what is happening. In August, my MRIs were approved. The results:

  1. Ankle — partial tear in tibiofibular ligament (bad news)
  2. Knee — severe bone bruise, Baker’s cyst (good news)

After finishing up physical therapy, and still in pain, I was referred to seek surgical opinions of Dr. Milap Patel (ankle) and Dr. Stephen Gryzlo (knee). While Dr. Gryzlo determined my knee was not a candidate for surgery, Dr. Patel is set to perform my ankle surgery November 9th. Since our family deductible was not met in 2017, this will cost me between $5,000-$7,000.

To recap, the June ankle/knee injuries that took until July to get physical therapy and until August to get MRIs, are now being surgically repaired in November. Not including Dr. Godo and Dr. Cayce, the HMO process has seen four different doctors — in three different locations — plus three different Athletico physical therapists treat these injuries. It has included three MRIs, two X-rays, and (hopefully only) one surgery.

The best points to remember are that (1) health care is fucked up (2) depend on yourself to take care of yourself.

 

Leave a Reply