Thursday, July 16, 2009

Rhonda in Pittsburgh, Pennsylvania (Roberto Clemente Park)

Rhonda in Pittsburgh, Pennsylvania (Roberto Clemente Park)
Originally uploaded by walk4healthcare

Rhonda returned to Pennsylvania to take care of her elderly family. She's had self-pay insurance via Highmark, the major insurer in the Pittsburgh market. “It's alright so long as you don't get sick.” Regarding the recent debates in Congress, she also added, “If you believe anything those execs put out, then you're a fool.”

She had a situation last year of right upper-quadrant abdominal pain. She went to the ER, which was an ordeal in itself. They started the work-up: a GI consult, surgical consult, ultrasound, HIDA scan were ordered and she was admitted for overnight observation. All the tests returned negative. Highmark denied the $7,000 for all the tests and the hospital stay, deeming that it was all 'medically unnecessary.' “There was no way for me to know they wouldn't cover it.” The hospital called for pre-approval, but the insurance company still had denied it. But Rhonda fought it, saying either the hospital was practicing fraudulent medicine or the company was wrong. They finally backed-off and paid.

Rhonda also described a story from a friend of hers who worked as a dental assistant. She had attended a conference on billing which the whole point of which was how to bill so the insurance company could deny the claim: what diagnostic categories to use, etc. The percentage of people who would NOT fight was estimated at 70%.

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