Below is the bulk of a text of an e-mail that I sent to one of the leaders at my job. The purpose was to explain all of the problems that I’m having with the insurance – frankly, some of this stuff is insane…

Prescriptions: The most aggravating issue that I have is the prescription coverage. My doctor prescribed a certain drug for a condition that I have, but he gave me free samples to use first. Once the free samples were completed, I tried to get the prescription filled and the pharmacy told me that the insurance company didn’t cover the medicine (first they said I wasn’t in their system – a recurring theme as you’ll see). Instead, I have to take two generics – the free samples that my doctor gave me were working very well, too. I don’t mind taking the generics, but now I’m inconvenienced with taking two pills instead of one.

Additionally, I tried to fill the generic prescriptions and one was approved with no problem while the insurance company wouldn’t immediately approve the second one. They wanted additional information from my doctor, which the pharmacy requested. The Pharmacist said that the process should take no longer than 2 – 3 business days, so given the upcoming holiday, I might not be able to get my medication until after Labor Day. [Note: I wrote this e-mail on Wednesday, September 2nd]

Gym Reimbursement: The insurance company has a Healthy Lifestyles program that I am enrolled in. This program offers $150 for reimbursement of gym membership expenses if you go the gym 120 times in a given year. When I switched to my new gym in March I asked if it was covered in the program and they said yes. On a following call with the insurance company, they told me that the visits to this gym would only count if they were made in between certain times of the day (basically when we’re at work). That effectively kills my ability to claim this reimbursement and it makes their program useless.

Request for Information: In one of these calls to the insurance company, I asked them for a package of information that detailed all of my benefits because I, unfortunately, lost the package that the secretary gave me when I was hired (I lost it in the move to Tinton Falls). They sent me a package for those members who are 65+ years old living in Somerset County. I called them back and told them that they must have the wrong guy and that I was 28 and living in Monmouth County while being employed in Mercer County. They apologized and sent out a new package…the same package as the first time. So I threw out both packages since I’m not a senior citizen living in Somerset County and gave up trying to ask them for a listing of my benefits.

Delta Dental: When I went to the dentist two weeks ago, I had to wait an hour before I could be seen by the doctor because the assistant was told by Delta Dental that I wasn’t in the system. Apparently, she called a few days prior to my visit and I wasn’t in the system then, either. I gave her our office contact information, but I was in the dentist’s office at 8am for an 8:15am appointment so there wasn’t anyone in our office who could help that early on a Friday morning. After waiting on hold and going back and forth with the insurance company, I was magically found in Delta Dental’s system and able to see the dentist at 9am.

Optometrist: The insurance company subcontracts their vision coverage to a vision company. I went to the eye doctor about four weeks ago and it took them over an hour to figure out how to bill me AFTER I had seen the doctor. They were on the phone with the insurance company who took no ownership over their contract with the vision company and said that I wasn’t even in their system (they eventually found me). So the eye doctor’s office called the vision company, who said to contact the insurance company. This went back and forth until someone finally got on the phone and figured out what to do and how to bill me.

Pearle Vision: When I was getting my glasses at Pearle Vision, the person helping me pulled up our company’s specific plan with the vision company and it cited that we had a really great plan that covered some parts of the equipment (great discount on lenses). Then when he called the insurance company to get some confirmation number, they wouldn’t speak to him and put him through to the vision company, who bounced him back to the insurance company, who ultimately said that we had no equipment coverage. The folks at Pearle Vision were baffled since their information (which had been updated about two weeks earlier) clearly showed all of the equipment coverage that we should be getting on our plan.

This is where my e-mail ends. However, there is an addition to this mess…

Nutritionist: It turns out that my nutritionist visit (which is essentially preventive care – the stuff that everyone in America should be engaged in) is not covered either. You see, my nutritionist is not registered as a medical care provider and thus can only enter a certain billing code to the insurance company. Well, my plan doesn’t accept that billing code – they only accept nutritionists that bill as medical offices. So I have to pay for this visit out of my pocket.

Here’s my question – if I’m paying for health insurance and I have all of these needs that aren’t being met by the insurance company…why am I paying for health insurance again?

Speaking of healthcare, one of the subscribers to this blog (by the way, have you subscribed to the blog yet? If not, go to the top of this page and subscribe there!) sent in his proposal to reform healthcare. It’s interesting, to say the least. Frankly, I think there is merit in the proposal, which is copied below from a recent op-ed:

A proposal to reform medical care and save the federal and state governments and the American taxpayer billions over the long run.

Federal and state governments would pay all costs of a medical school education for students who otherwise would not be able to afford a medical school education. No student would be excluded, provided that upon completing medical school, the doctor would be obligated to provide a percentage of their time and practice for treating low-income patients deemed eligible by federal and/or state governments.

The doctor would be obligated to treat a small percentage of eligible low-income people for free (office visits only). The percentage and number of years of obligation to do so would be decided by peer review. The less money provided to the students for their medical education, the smaller the percentage of their obligation for treating the eligible poor.

Participating doctors would not bill Medicare, Medicaid, insurance companies for the treatment of the eligible poor, thus saving federal and state governments billions of dollars in the long term.

The cost of the free medical school education provided by federal and state governments would be offset by the savings achieved by not having doctors bill Medicare, Medicaid and the insurance companies. Students in any stage of medical school would immediately be eligible to participate.

Doctors would have the option to treat eligible patients in their office, at hospitals or clinics. Clinic space could be provided for out of office visits.

The same premise can be applied for health providers and caregivers willing to participate under the same above rules and obligations. The federal/state governments would defray all cost to all eligible health providers and caregivers to open up their medical practice/office. Doctors, labs, chiropractors, and therapists would be eligible under my proposed program.

The potential saving to the federal/state governments from non billing by participating caregivers would be enormous.

Regarding unnecessary diagnostic tests that are ordered by doctors out of fear of medical malpractice, a meeting of the minds could be convened among federal and state policy leaders, bar association representatives, medical insurers, and health providers, to come to an agreement of understanding as to limiting diagnostic tests deemed unnecessary.

Joseph P. Martino
Millburn, New Jersey

What do you think?

By the way, this is a new doctor for me so I went there a few minutes early to fill out the requisite paperwork – which wasn’t so bad. Also, my appointment was for 9:30am and I was called into the examination room at 9:32am. Talk about fast and speedy!

The nurse took some of my blood for blood work and then took my blood pressure, which was exactly where it should be. The first sign of good health was that I didn’t have high or low blood pressure (I normally have low blood pressure). The doctor then came in and talked to me about my stomach and since I hadn’t had the annoyances in the last week, he thought that it might not be a big problem. However, just to be sure that it didn’t have anything to do with my heart, he gave me an EKG. I never had one of those before, but it’s an extremely quick little procedure.

The nurse told me that this procedure checked to see if there was plaque build-up around my heart and whether or not my heart was beating correctly. Again, I was happy that the test showed no build-up and that my heart was beating normally. More good news. The doctor wound up giving me some preventive medication for a twenty day period. I’ll go back and talk to him when the medication is complete, but I don’t have any symptoms of the heart burn or a possible ulcer any more.

Since I was in the mood to see doctors on Friday, I went over to the optometrist to get my eyes checked. You’re supposed to get an eye exam every year or every other year if you’re younger. It’s been six years since my last eye exam, so I thought it was time to get back to the doctor. Again, this was a new doctor for me and while I had a very pleasant experience at the general doctor in the morning, I had a horrendous experience at the optometrist.

I went to the “Eye Doctor” next to the ShopRite in Neptune, Monmouth County. It was the worst pre-examination experience that I’ve ever had at a doctor’s office. I arrived at 3:15pm for a 3:30pm appointment – I figured I would have some paperwork to fill out (which I did) and then there would be a small wait before I saw the doctor. Oh no…

My paperwork was completed by 3:20pm and I wasn’t called in to see the doctor until 5:00pm. I repeat. My paperwork was completed by 3:20pm (for my 3:30pm appointment) and I wasn’t called in to see the doctor until 5:00pm (1 hour and 45 minutes after I arrived). Folks, it was pathetic. I’m not sure why the place was running so slow or if it was a problem of overbooking, but the atmosphere was just as bad as the wait. For nearly two hours I sat in a “waiting room” listening to vagrants on the outside of the doctor’s office hooting and hollering in public – like ANYBODY wants to hear that crap. It wasn’t so much better on the inside with kids running around and adults hollering inside the store like children. It was like I scheduled my appointment during the time when they let the animals loose.

What was most perplexing about the entire experience was that the optometrist was amazing. He ran a number of tests on my eyes that I don’t remember ever having before. And (just as in the morning) I received a completely clean bill of health for my eyes. The doctor did give me a new prescription for my glasses, but the funny thing is that the prescription is for a lesser strength lens than I currently have. In other words, my eyes have gotten better over the last six years! Ha!

In the next week or two I’m going to try to get to the dentist. That way all of the major appointments are taken care of and I can wait another year or two until I go back for another check-up!