Your Health Insurance Carrier – Friend or Foe?

| March 9, 2010 | 0 Comments

Posted by Hiland on March 5, 2010

Health insurance is on the scene and in the news.  It should be.  During my 10-year battle with heart disease, a sound health insurance plan was the grease that turned the wheel.  Without the coverage and cooperation provided by my carriers, my transplantation would never have happened. 

I was satisfied with my original carrier, who covered all events surrounding my first series of heart attacks as well as life-saving six-way bypass surgery.  The staggering costs of procedures, hospital care, after care rehabilitation and medications were mind-boggling and unaffordable.  My original health insurer stood with me and behind me, and, quite possibly, in front of me every step of the way.

Health insurance has always been important to me.  As a former employer of many relatively low-income, non-union laborers, I felt that a fully paid health insurance benefit provided necessary incentive and assured longevity and peace of mind.   Before the premiums exploded, we provided this fully paid benefit.  Undoubtedly, many overqualified workers stayed with us because of that health insurance.  Of course, health insurance did not prevent underachievers from underachieving, but they sure stayed longer!  Another chapter.    

Approximately two years after my open-heart surgery, I was rushed to the emergency room.  I don’t remember what happened.  I awakened on the floor of the kitchen in a bad way.  Pea soup was dripping from the ceiling.  I was treated in the emergency room and visited by my loyal cardiologist, John, who thought it wise to spend the night.  Against my wishes, I agreed.

Apparently, the carrier disputed the validity of the overnight claim.  Occasionally, I received frustrated calls from the credit department at the hospital.  Of course, I got the brush-off from the carrier, but each time I called they agreed it was a valid claim.

In any case, I shifted our company policy to another, local provider, that had been founded by Jack, a friend and physician, now deceased.  From the patient’s perspective, there was an immediate and noticeable difference at every level of service. 

My sense was  that Capital District Physicians Health Plan (CDPHP) was committed to getting it right, the first time around.  Regrettably, I was a bad risk.  I can only apologize for that. 

The support, patience and counseling I received from CDPHP, their out-of-network provider, United Health, and my very special CDPHP transplant health coach, Paula, are the reason I arrived at Tampa General and one of the main reasons that I am alive today. 

It may be fashionable to be negative about health insurance, but my experience with CDPHP could not have been better.  Every day, I think of their role in my longstanding battle with heart disease.  I praise this provider at every opportunity.

That does not mean that patients do not have to engage the carrier or become informed about their treatment.  Frankly, if you are pursuing a heart transplant, you must embrace your new partner, not battle them. 

It is the patient’s responsibility to ask the right questions of your physicians, try to understand the answers and communicate with your carrier every step of the way.  If in doubt, make the call.

It is also the patient’s responsibility to address the transplant process with as much vigor as possible.  During the fight against heart disease, there will be many things in your life that may be unmanageable.  For me, CDPHP and health insurance were not among those things.

You must be a responsible consumer and patient. Open the doors of communication and walk through them.  Get pre-approvals at every reasonable opportunity.  It saves time, paperwork and aggravation.  Document everything.  If you are incapable of managing your insurance, find someone in your support network that can. 

I do not believe that your health insurance experience has to be negative.  I believe it should be positive.  I submit that you are the one that determines how that relationship goes.  I don’t want to beat it into the ground, but staying ahead of the treatment-insurance interaction facilitates the entire treatment process. 

I can say in all honesty and with complete confidence, that were it not for Paula, who I have never met, I would not have a new heart today.  Thank you, Paula and thank you CDPHP! 

More to follow.


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