Mangled care

Mrs. Gerbil and I finally went to see Sicko last night. I was very impressed. I'm not a Michael Moore groupie--perhaps because my parents had me watch Roger and Me when I was a mere pre-teen, and I was rather bored by it--but I do appreciate a good exposé when I see one.

And it got me thinking about what I currently do for a living.

The insurance group I work for was not featured in Sicko. My actual company was not even mentioned; the behavioral health insurance system is a whole 'nother movie. So in that sense Sicko was not about what I do 40 hours a week.

Another sense in which Sicko has nothing to do with my job is that I never have to deny coverage for any individual person. I can tell a member that his plan does not cover couples therapy, but I never have to say that his particular request for couples therapy will not be approved. There are two reasons for this little bit of relief. First, "adverse determinations" can only be issued by reviewers with clinical licenses. Second, as long as a person's plan permits a specific type of treatment, it's my job to say "yes."

(And here's a third sense: I hear that the medical carrier under our corporate umbrella no longer does procedure reviews, as nearly all requests were being approved anyway.)

But this movie was about what I do simply because I work for managed care. I believe that the health care system in the US should do its darndest to promote preventive care. HMOs--health maintenance organizations--started with this very same philosophy. I also believe that, when a person needs medical treatment, he or she should get it. There shouldn't be a need to call within 24 hours of admission, or to expend time/money/emotional effort filing appeals, or to hire an attorney... or to have to decide to skip treatment altogether because insurance won't pay. Health care should not be about money--and there is where the Big Bad System and I diverge.

All of my statements above, about why Sicko doesn't point its finger at me personally, are really just displacements of blame. Like most of my co-workers, I took my job because Mrs. Gerbil and I were hurting for dough. It's been less than six months since I began, and already we're financially back on our feet. And (not surprisingly) we get really cheap health insurance, with more-than-decent coverage for what we're likely to need. Yup, managed care treats its employees well; and I think my company is one of the best in this regard.

Still, I'm part of the Big Bad System, and I'm just doing it for the money. My paycheck might not be the direct result of in-house adverse determinations, but many of our plans are carve-outs from other medical carriers. And those carriers do issue adverse determinations. There aren't many degrees of separation here.

So, no. I'm not directly involved. But lest I be accused of sounding like a complacent WWII-era German (Godwin's Law, anyone?), I hasten to point out that I do have a well-established history of fighting the system.

And on that note, I offer the following tips to anyone who might need them:

1) If you have insurance, read your Evidence of Coverage Document. Cover to cover. As soon as possible. Call member services if you don't understand the terms of your policy.

2) If you believe your claim has been wrongly denied, raise a stink. File an appeal. File a second appeal. Then contact the state oversight body for your plan. This might be the state board of insurance, the state commission on managed care, or some other such body; and you can find out which one applies with a single phone call to member services. Just don't call me about your claims.

3) If you get stuck with a huge hospital bill, contact the patient advocate about financing options.

4) By federal law , virtually all US hospitals are required to provide examination and stabilization treatment for truly emergent patients, regardless of their ability to pay. If your plan refuses to cover non-network care you received while completely unconscious, raise a stink (see #2 above).

5) Above all, don't give up. A cynic might say that somewhere, someone is counting on you to give up ("Baby needs a new pair of shoes!"). But I am not that cynical. Yet.

(For the record: Appropriately, I used a tiny little portion of my paycheck to take Mrs. Gerbil to the movies.)