“THE DEVIL IS IN THE DETAILS.”
In my May 1 blog I related how I put $283 for boat parts and $273.21 for a shingles vaccination (Zostavax) on my Visa card on the same day. The boat part purchase was as simple as that. For reimbursement of the cost of the “shingles shot”, a covered service, I was instructed by the physician’s office to submit a two-page claim form containing five unique identification numbers with copies of all the relevant bills to Caremark, my Part D Medicare pharmacy contracted by Blue Cross/Blue shield . Two weeks later I received a check from Caremark for $137.52 or 50% of what I paid at the physician’s office. The space in the accompanying letter explaining the reimbursement, ie. why wasn’t it for the full amount, was blank.
I called Caremark on May 6 and after some discussion confirming that the shingles shot was a covered service according to their formulary and website, I was told, “You went to an out-of-network pharmacy”.
“I didn’t go to a pharmacy. I went to my doctor’s office. The nurse gave me the shot, and I paid the bill” was my response.
After some more discussion the Caremark telephone voice said she would forward the claim on to “Paper Claims Review”, and that if I called back in 72 hours using my claim reference number of 15722355 I would learn the result of the review.
I called back 6 days later and was told that the claim was “still under review”. I asked when the claim had been sent to Paper Claims, and she responded, “Let me see”. After a brief hold, faint computer sounds returned to the phone, and she said, “It went to Account Management on May 12.”
“That is today”, I said. She agreed and said that I could call back in 24 hours to find out the result of the review.
Four days later I called back and was told that the claim was “still under review in Account Management because you used an out-of-network pharmacy”. After repeating that I did not go to a pharmacy but to a physicians’s office as clearly documented by the bill I submitted with my claim form, I suggested that perhaps I could clear this up with a direct call to the Account Management Department.
“Accounts Management has no telephone number. You can’t call them directly.”, was the response. Suppressing my incredulity and growing frustration I continued the conversation in hopes of finding a way of resolving this small but vexing impasse. I was told to call back in 72 hours.
Two days later I listened to a message on my answering machine from Caremark asking me to call them back. No reason was stated and the central number was given for the call back.
I called the Caremark central number the next day and was told again that the charge was not fully reimbursed to me because “I had gone to an out-network- pharmacy.” After some discussion with the telephone voice who put me on hold twice while she seemed to be searching for a solution, she suggested that I resubmit the claim. I wondered aloud whether filing an appeal would be more effective, and she said, “No, just resubmit the claim”.
So I filled out, again, the two page claim form with the five, long, unique identifying numbers, included the bill from the physician’s office, copied the whole batch, and sent it off to Arizona. Within a week I got Caremark’s notice of denial as a “duplicate claim already paid”.
By this time a mere mortal probably would have given up, but because I am interested in how systems work (or don’t), have an abiding interest and some experience in health services management, and am always looking for stories for my blog, I decided to persist. But I took a different tack.
I called Caremark, pushed the phone key for “benefits”, and asked “How much will it cost me to get a shingles shot?” After some conversation clarifying my request the telephone voice told me that I could go to a pharmacy with a prescription, get the vaccine, and take it to the doctor’s office to have it administered.
“How much will that cost me”, I asked.
“There is a $44 co-pay”, was the response.
“Is that for the vaccine or the administration?”, was my next question. She put me on hold to find out. When she came back and reported that the $44 was the co-pay for the vaccine, I told her my story of being reimbursed only half of what it cost me to get it in a doctor’s office, and I was trying to figure out the least expensive way of getting the immunization.
“Can I put you on hold again, please?”
When she came back she did not have an answer about the co-pay or any deductible for the office visit, but she reported that “$135 is the maximum reimbursement for that service.”
I never did find out if that was because of a co-pay, a deductible, a penalty for “using an out-of-network pharmacy”, or it was just what Caremark would pay. I also asked my local pharmacist what the cost to me would be for the immunization, and he responded, “It depends on your insurance. I have seen it all over the place. The highest reimbursement I have seen is about $135.”
So, the way I figure it, since the physician’s office charged me $46 for administration of the shot and the vaccine would have cost me a $44 co-pay at the pharmacy , I could have gotten the immunization for $90 instead of $135. But I’ll never really know. This is a small difference in money, but is a concrete example of the lack of transparency and complexity of our current “single payor”. We have a long ways to go before there is enough transparency to sustain an informed consumer.
… maybe I’ll file an appeal. Just to see if I can learn something more about the reasons behind this ridiculous process.
This scenario is replicated hundreds if not thousands of times a day and I have experienced it personally and professionally. As long as insurance companies make money by not paying for services that you use, there is good reason for them to make reimbursement as complicated and painful as possible. Mere mortals would give up and pay the bill. I have saved thousands of dollars by pursuing claims until the insurance company is forced to pay for the services I use per the insurance agreement between them and me. The system is broken with no sign of relief in sight.
Let’s hope after all of this that you don’t get Shingles.