health insurance fraud?? part 2
After a number of days and several phone calls
it seems that the Anthem Blue Shield rep was not completely accurate on some things but correct on others. The good news part of "...not completely accurate...
" is that Bruce's hospital bills shall be covered under Blue Shield. So it turns out that for the moment at least, it may have been resolved.
Here's what happened.
The Blue Shield rep called me back and over ther remaining days of the week she and I walked through other messy bureacuracies.
First she said the hospital submitted the bill to provider/vendors in the wrong sequence. Hospital stays, for Medicare Part A eligibles, must be sent to Medicare first. Medicare then sorts out the actual hospital charges [room stay, ER visits, direct care staff hours, those five dollar aspirins, etc] THEN leaves the remaining costs to be borne by the secondary vendor; in this case, Anthem Blue Shield.
The "secondary costs" include physician consults [our local hospital ~ for example ~ noted to me that none of the docs are employees. They are, instead, independent contractors "privileged" to serve their clients at the hospital], diagnostic tests, X-rays, CT Scans, MRIs etceteras, and the secondary provider picks up these costs AFTER direct hospital costs are shaken out.
So where did the denial by virtue of us being domestic partners [whatever] come from? Well, that got complicated. When she first called Medicare and alerted them of our same-sex spousal "condition" [emphasis was hers]she got a lecture from the Medicare rep who told her that since they are a Federal program, and since the Feds define "spousal" as only male/female, that Medicare has subsequently interpreted their regs to apply the same way. She mentioned that he also stressed that "this means for pensions, too". She told me that Medicare was just trying to make sure I knew that if one of us dies, then the other doesn't get the Social Security pension of the other. Doh! I guess the stranger at Medicare thinks I never read the papers.
When she'd gotten that info, she called me back. Fresh from the phone conference with him [she did say the Medicare consultant was male] she came right back to me to tell me, with a tone of authority, [tho' first skirting specifics] that since Medicare wouldn't pay the bill, then neither was Anthem Blue Shield obliged to.
That was when I asked her if this was just because we were "a couple of queers" and questioned her about Anthem possibly engaging in contractual fraud with the State of Connecticut.
That gave her enough to think about so that by Friday, and four conversations later, she announced the problem solved and that we no longer had to worry about non-payment of medical expenses.
She also provided a backhanded verbal flow chart describing how the hospital has to bill for services. In our case, BC/BS was sent the whole bill first. Some lower functionary at Anthem spotted that Medicare didn't get the bill first. This supposedly triggered the process whereby both service providers [...wait, they are VENDORS ...purveyors of money nothing more...] denied the claim. I'm still uncertain whether or not I follow this, but she says the bill's getting paid, the bill's getting paid. She cautioned, however, that I needed to do a direct conversation with the hospital's billing department about the SEQUENCE of billing out. I thanked her.
The explanation got revised to clarify that Medicare Part A covers the actual hospital visit. Any other medical expenses [physician consults, diagnostic exams, other] that would have been covered under Medicare Part B [Bruce doesn't have this coverage right now] gets picked up by Anthem Blue Shield, as it ought to.
Somehow, since I had constant and incessant problems with Blue Shield Dental [they kept saying there was no way to "code in" domestic partnership arrangements in their computer system. Could the fact that their tech support people are based in Utah have anything else to do with this?] I remain uncertain. Until I actually see the bill as paid I'll remain wary and shall stay at it until there's a zero balance on the hospital's ledger sheet.
This then still remains a battle with the Feds, with the Shrub, Karl Rove, and Dubya's Shadow Cabinet [Ann Coulter, Donald Wildmon the whole caboodle of hateful bigots] that run and/or influence the doling out of equity these days which needs to be addressed.
We may have to wait of the day when election rights are once again restored before THAT gets corrected.