Thursday, May 8, 2008


Catherine Wilson, Bureau Chief
Northern Westchester


The Medical Insurance Maze

The Empire Anthem Blue Cross/Blue Shield medical insurance provider recently sent out a letter to local plan participants that several
Westchester hospitals were discontinuing their contract with Anthem. Anthem assured their plan participants that they would continue to
negotiate with the hospitals, but advised patients with surgeries scheduled for later this year to seek another hospital to have their procedures
handled elsewhere.

These letters are becoming more common and the instances more varied as insurance companies, medical providers, and employers alike seek ways to rein in their skyrocketing health care costs. But caught in the middle are the patients who have come to rely on a specific doctor, hospital, medication, and insurance plan for their ongoing care. The Guardian spoke with several of our local government representatives
and residents concerning the problems they are experiencing with their medical insurance.

Janis Morris, the Director of Constituent Services for New York State Senator Andrea Stewart-Cousins, 35th District, spoke to The
Guardian about specific instances where local residents have sought the Senator’s assistance in resolving their medical insurance difficulties.
“We had a grandmother come to us about the medication her granddaughter was using for severe acid-reflux problems,” Morris told us. “The child could not digest food and depended upon this formula. But the medication became an “over-the-counter” product and was no longer covered by a prescription policy. The family had to spend $50 a can for this formula, or more than $650 a month, which they could not afford.

Our office had to prove to the insurance company that this was a life-threatening situation to get them to switch back to accepting prescriptions for this medication”. Pharmaceutical companies advocate switching their products to “Over-The-Counter” access, thereby circumventing the need for a doctor’s prescription, under the assumption that this will allow greater access to these medications. In reality,
the opposite is often true.

A patient, who paid a co-pay of $10 or even $30 for a medication for a monthly supply of 30 pills, may now be faced with shelling out at least that amount weekly for just 12 tablets that are no longer covered by insurance. In 2002, Schering-Plough announced that they would be releasing their allergy medication, Claritin, over-the-counter. Millions of allergy sufferers, faced either paying for this medication themselves, or having their doctors change their prescriptions to another, more expensive product such as Clarinex, made by, of course, Schering-Plough.

But the medical insurance companies fought back and started denying payments for any type of allergy/asthma medications claiming that these patients could now all use Claritin and pay for it themselves over-the-counter. Asthma victims, this writer included, who rely on daily doses of Singular to ward off severe life threatening attacks, were told by their insurance companies that their prescriptions to their allergy
medications would no longer be covered since they could use Claritin instead.

Asthma patients had to file appeals to the insurance companies explaining to them that a hay-fever attack was a different medical problem from asthma and therefore could not be treated with the same medication. Sadly, many local patients face equal frustrations and illogical behavior from their insurance providers in all areas of their medical care.

Ms. Morris gave an example of how insurance companies deny treatments to the elderly on Medicare. “One couple selected an HMO (Blue Cross/Blue Shield – BC/BS) as their insurance provider and had their monthly premiums deducted from their social security checks. At one point, the husband needed to go to the hospital and BC/BS denied his admission telling him that he never paid his premiums. The patient immediately paid his premiums himself and was told he would be reimbursed. It took six months to get the reimbursement”.

Ms. Morris said that there is now a new ruling prohibiting insurance providers from contacting the Medicare recipients directly about premium problems. The insurance providers must now contact Social Security to fix the problem, keeping the patient out of the loop and avoiding instance like this one where an elderly person on Social Security is forced to foot the bill for something they’ve already paid for.
But many medical insurance mix-ups can take years to resolve. The Guardian spoke to a young widow, Marie, about her two-year struggle to resolve the payments of her late husband’s medical bills (her name has been changed to protect her young family’s privacy). Marie’s husband died of cancer in 2006, leaving her with four young children to care for alone.

He had been in a local hospital for over a month, showing no signs of improvement. The hospital recommended moving him to a respite/nursing facility where he spent the final six weeks of his life, until the night he died when he was rushed back to the hospital emergency room for his final hours. Shortly after his death, Marie received bills from the nursing facility for her husband’s stay. A few calls
to his medical insurance company revealed that his policy allowed for 100 days of nursing care and he had only used 45 so there was no problem with covering these bills. Two years later, the insurance company is refusing to pay claiming the facility and the nursing care it provided is not covered under their plan. The facility, in turn, is now sending threatening letters to this widow seeking to collect this debt.

“I have not been able to take the time to grieve for my husband with dealing with this for the past two years,” she told us. “I am so sick over
these bills. They are almost $30,000. My husband would be heart-broken to know his family is being treated like this. He died thinking he had provided for us. He worked so hard all his life to do the right thing for his family. How would he feel if he found out that all the precautions he had taken so much trouble to set up were now being rejected and his family was being hounded?”

Marie has shut off her answering machine and won’t answer her home phone anymore without checking the caller-ID first. “I can’t return
phone calls on this any more – I have to psych myself up to be able to talk about this. I get sick to my stomach every time the mail comes – I’m afraid to see what’s in there. I have two children in college this fall and two younger ones coming up. Why am I being asked to pay $30,000 when my husband had plenty of medical insurance to cover this? What was he paying premiums for?”

Marie’s case raises the issue of how the use of a particular facility should be determined and who is best suited to make that determination.
In her situation, no one could expect a young mother, with four young children around her, to think of whether the insurance company
would pay for the nursing facility at a time when she was dealing with the impending death of her husband and her children’s father. So why didn’t anyone at the hospital call the insurance provider up front to get a written confirmation that this transfer would be approved? The hospital stay for Marie’s husband was covered in full by insurance. Ironically, if he hadn’t been transferred to another facility, at the hospital’s recommendation, she wouldn’t have this problem. So why was her husband transferred out of a facility that was being covered by insurance into a non-covered one? Who should be responsible for making that kind of decision? And why should the patient (of their family) be expected to pay for these mistakes when they didn’t make this decision?

A review of Marie’s bills also revealed another disturbing fact. Just one night in the emergency room alone cost over $10,000 for her husband’s care. Yet the hospital settled with the insurance company for less than $2,000 for his treatment that fi-nal night. Is this actually the rate and, if so, who pays it? Does that mean that local residents without insurance would have to pay this hospital the full $10,000 for a one-night stay in the emergency room? Or was the hospital deliberately upping its charges to the insurance company knowing that they would be reduced? One of our local state representatives is working with Marie to resolve this issue. In speaking with several representatives on this issue, The Guardian learned that resolving medical insurance problems for their constituents takes up a significant portion of their time. “Approximately one-third of the state budget is dedicated to health care,”

Assemblywoman Sandy Galef, 90th District, told us. “And we do spend about that much time on these issues for local residents. We often
get the call that the person has insurance but their particular problem is not covered. Or they have been dropped from their insurance.”
(Assemblyman Greg Ball’s office confirmed this estimate). Galef noted that many of her constituents have problems affording medical insurance to begin with. “We put them in touch with the plans the state has, such as Child Health Plus for children, Family Health Plus for families and individuals, and Healthy New York for small businesses. We also have a prescription discount card for our disabled residents or residents who are 50 -64 years old and do not qualify for Medicare yet.

People are often surprised to learn that they qualify for these plans – they often make the false assumption that their income is too high to get help. The New York State Department of Health is doing more publicity to get the word out on these programs so that our residents
will take advantage of them”. Assemblywoman Galef also noted that Albany’s approach to the health care issue has changed. “In the last budget, we have shifted dollars to out-patient care and community health centers. We are putting more money into prevention so that
people can deal with their medical problems up front and don’t end up in emergency rooms”. New York State is also advancing other programs. “We are providing nursing visits for low-income first time mothers on prevention issues like better nutrition.” Galef advises
that their offices, like the offices of all local representatives, can offer local residents help in all medical areas. She said, “My office assists local residents with concerns regarding nursing homes and VA hospitals. We can deal with the insurance issues – we have contacts at all of the HMO’s and we try to open up doors for our constituents. If we have to, we can take the matter to the New York State insurance department for them”.

There are some steps local residents can take to offset the costs of their medical care. The Westchester County Department of Health
can assist residents with the New York State insurance plans. They can be reached at 914-813-5048. The county department for Seniors
(914-813-6400) can assist with the elderly pharmaceutical insurance coverage plan (EPIC). And, individuals without prescription coverage, can reduce their out-of-pocket expenses by comparing the costs of their medicines at local pharmacies on the New York State Department of Health web site www.rx.nyhealth.gov.

A quick check by this writer of prices of common drugs revealed wide discrepancies in prices in our area. Xanax ranges from $13.28 at the Sound Shore Pharmacy in Mt. Vernon to $181.93 at the Main Street Surgical Supply in New Rochelle. When all else fails in dealing with a medical insurance problem, a patient does have the legal right to an appeal. Again, the New York State Department of Health can assist with this. Their web site has forms and instructions for how to initiate an appeal and what the consumer’s rights are and even what to do if the appeal is initially denied.

Our local representatives and the county office can further assist local residents with these issues. Dealing with a medical condition is difficult enough without having financial and insurance problems to boot. As The Guardian saw in Marie’s case, she feels so trapped
in an insurance nightmare that she is not even able to grieve for her late husband. The Guardian will stay involved in her case and will hopefully be able to report success back to our readers in the not-too-distant future.