I complain quite a bit about my healthcare plan (I wonder what person with a chronic disease doesn't?), but truthfully, most of my complaints should really be directed not at my insurance company or even the plan itself, but at all of the accompanying health reimbursement account/"HRA" (which although generous, still required all kinds of additional paperwork) administrative stuff that I need to deal with in order to get even the most basic medical treatment stuff paid for. My HRA pays for everything (except the first $500) until my insurance company deductible has been met, because it's much cheaper for my employer than to pay for things this way than it is to pay the higher premiums associated with a lower-deductible plan. In essence, I must file claims with both my insurance plan, and HRA to get things like doctors' appointments or even simple laboratory bloodwork paid for. Anything not covered or left over is paid for by a separate flexible spending account. All of these are tax-advantaged accounts, and whenever the IRS gets involved, there's paperwork.
It is (or I should say was) a paperwork nightmare, submitting every claim in triplicate to the insurance company first, waiting for an explanation of benefits to arrive from the insurance company indicating how much they will allow towards the deductible and that they have paid nothing until that deductible amout is met, then also submitting the same claims to various reimbursement account administrators (HRA and FSA), and then trying to keep track of all of the many, many I claims I submit for insulin, testing supplies, labwork and the like. I spent hours and hours dealing with this so-called "world-class" healthcare system just to get basic services paid for, and I hated every second of it.
My last HRA administrator would send payments (via direct deposit) with absolutely no documentation of which claims were even being reimbursed, just an adjusted dollar amount and I had to try and figure out what claims the payment was for. Last year, I had to complain to my HR person that over $1,750 in claims (which I had paid for out-of-pocket and was now incurring finance charges on from my credit card company) had not been reimbursed in over 7 weeks, in spite of a service guarantee that they would be repaid within 10 business days. Fortunately, I had return receipts for all of my claims, and they were resolved pronto once I complained about them (although I still incurred finance charges that were NOT reimbursed), but it was a royal pain-in-the-@$$ to deal with.
My employer also had problems with the reimbursement account administrator (for example, they changed the process for having claims processed using a different web host and never bothered to tell my company about it, which explains why I had $1,750 in claims that weren't processed), and fortunately, there is an entire "industry" dedicated to this. Naturally, this industry has a trade organization called the Employers Council on Flexible Compensation (ECFC).
That's why I have a very RARE compliment to make about something that actually DOES work, but it's one I felt was worth sharing because, as I learned, things really do not HAVE to be such a burden.
PWDs: PCPs, HRAs, HSAs, FSAs, even the FDA ... Do We Really NEED Any More Acronyms in this "system"?
I use the term very "system" loosely to describe the way healthcare is paid for in the U.S., because it's a euphemsim, but certainly NOT an accurate description by any stretch of the imagination. The term "system" implies that everything works together in order to provide optimal healthcare. Instead, the U.S. "system" is really a group of self-interested, for-profit providers all very eager to get paid, but with little genuine regard or even interest (unless it saves them money) for what's really in the best long-term interest of the patient.
In this "system", everyone skims something (profit) from claims yet patient outcomes seem to be at the bottom of the list in terms of how things actually work. There are a few rare exceptions: for example, a true Health Maintenance Organization (HMO), Kaiser Permanente which operates mainly in California, actually does a better job of coordinating care for a patient as a whole. Although many people covered by Kaiser still gripe endlessly about getting costly devices like new insulin pumps covered, and the formulary really does not offer much of an exception process for covering non-formulary drugs even when a person who really cannot use the chosen formulary brands. But in the grand scheme of things, this model really does provide better overall care rather than the disjointed, "everyone for themselves" business model that pretty much defines U.S. healthcare today. I was covered by Kaiser when I lived in California back in the 1990's and honestly, had no major complaints with it, unlike my mostly negative experience with WellPoint/Anthem Blue Cross-Blue Shield.
My current healthcare plan arrangement is one of the ways that smaller companies deal with runaway healthcare costs which consistently exceed the overall rate of inflation, often by quite a bit. Because smaller companies do not have the buying power and clout that large firms do, the insurance companies are anything but shy about passing costs on to their clients. While healthcare reforms slated for 2014 may help to alleviate some of these issues, that's still 3 years from now. I have to deal with this so-called world-class healthcare "system" frequently until that happens (and it assumes that recently-elected lawmakers will not be successful in changing things on a wholesale basis).
A few years ago, I wrote (see HERE) about how my employer had switched healthcare plans (and we do NOT have a choice of plans to choose from) three times over 3 years. That's due (in part) to costs that increased, on average, 27% per year. But insurance companies also play stupid games with pricing. They lure new clients in with cut-rate pricing, and then, a year later, they jack their prices to make up for the sweet deal they gave away initially. Many small companies respond by switching plans readily. My plan-year also ends June 30, compared to November 1 for most other firms.
I think have noted before that my employer offers healthcare insurance, but no choice in plans. The plan, incidentally, is a very high-deductible plan ($2,500 per person/per year) which means very little is actually covered by the insurance company until that deductible has been met (except for certain things which are required by state law, such as testing supplies, but not medicines like insulin — go figure!). However, by using plan doctors and services, I am able to enjoy the negotiated rates for doctors, labwork, pharmacy benefits, etc. that would otherwise be unavailable and unattainable to me as an individual.
My employer also generously picks up most of the cost of my insurance deductible with what is called a health reimbursement account ("HRA"), which means that once I've paid the first $500 out-of-pocket (which I can pay for using pre-tax dollars via a flexible spending account ["FSA"] which reduces my taxable income and therefore annual tax liability). After the first $500, the remainder of my healthcare claims are pretty much reimbursed via my employer's HRA, except my co-pays.
I made some adjustments to my FSA since I had more left over than I anticipated last year, and also thanks to changes in IRS guidelines some OTC (over-the-counter) things now require a doctor's prescription to be covered. Not a big deal, but it's yet another hassle from lawmakers that seem more concerned about helping industries who lobby them most than they do addressing the issue of runaway healthcare costs.
But the paperwork was an absolute freakin' disasterous nightmare. But this year, thanks to the issues I noted above, my employer dumped their former HRA/FSA administrator and selected a new firm that could also handle transit arrangements, specifically a Federally-sponsored program which enables employees to pay for mass transit using pretax dollars. They selected a firm named The Choice Care Card, administered by a rapidly-growing, Vermont-based company. What an incredible difference that has made, and I mean that in a good way!
I am also fortunate enough to have a dental plan, which although not funded by my employer, still enables me to pay for this plan, again using pre-tax income. I selected a maintenance organization largely to have access in case of dental emergencies, but have been delighted with my primary care dentist, who is a recent dental school grad with a brand new office right in my neighborhood. This year, I needed a new crown to replace one that was being uprooted by a wisdom tooth that was growing into my old crown. The co-payment cost for this was only a $200, compared to several THOUSAND dollars I paid for when I had the original crown put in a number of years ago. To pay for it, I used my healthcare debit card to pay for the co-pay, and got an e-mail a few days later asking for substantiation. I asked the dentist to fax me a copy of the procedures I had done and the charges for each (co-pay amounts), which arrives as an Adobe Acrobat file in my fax inbox. From there, I just had to upload that document to Choice Care Card's website on the particular charge/claim in question, and voila: substantiation complete. It took all of 2 minutes once I spoke to the administrative assistant at my dentist's office and received the documentation.
The difference in this system compared to the previous one is light-years ahead. These various tax-advantaged accounts (HRAs, FSA, etc.) are meant to assist U.S. residents with healthcare costs, but they DO NOT have to be an administrative nightmare, as this example has proven to me.
If you are dealing with annoying paperwork and the like, realize that there are vast differences in the capabilities of the administrator your employer hires to handle these accounts. Of course, employers are the one's to select an administrator, but enough complaints about reimbursement might prompt them to select a new vendor, as was the case with my employer starting January 1, 2011. So far, the amount of time I've spent on seeking reimbursement for claims has been just a few minutes each time, not days and days.
I call that a rare compliment!