Sunday, January 15, 2012

End-of-Year Reconciliations; New Year, New Insurance

Happy New Year Everyone! What would a new year's post be withough including the awesome ABBA song "Happy New Year" (it's Flash audio, sorry for the Apple loyalists who really can't enjoy it the way the web was truly meant to be enjoyed) in honor of the occasion? See HERE (it's a Vietnamese site) to download the MP3 to the song (it was working when I wrote this post).

But beyond New Years tunes from 1970's-era Pop Stars from Sweden, the "Happy" New Year had a particular meaning for me in 2012, at least when it comes to managing diabetes. I ended 2011 much like I've ended prior years. I spent part of the last few weeks of 2011 (I began shortly before Thanksgiving) trying to make sure all the t's were crossed and the i's were dotted when it comes to the byzantine healthcare coverage system. I can be thankful for having coverage, but am less-than-thankful at how freakin' complicated all of it is.

Part of my year-end process also included making my last 90-day supply orders from Medco for the year, especially since I had a very high-deductible plan and because insurance was finally paying 100% of these orders at the end of the year I wanted to get what I was entitled to IMHO. Of course, that starts all over on January 1, so at least if I was able to stock-up, I should have sufficient supplies for a few months into the new year.

Personally, in spite of the big cost-savings for insurance companies, I find absolutely nothing convenient about mail-order pharmacies. Notably, I can't have them shipped to my apartment because stuff literally tends to disappear from my doorstep (I live in the city) or worse, dogs treat packages left at my front door like a fire hydrant. Either way, "home" delivery simply isn't a viable option. Of course, I am seeing both CVS and Walgreens are now promoting the ability to fill 90-days of scripts at the retail pharmacy, provided of course, your plan ALLOWS retail pharmacy fulfillment (my plan did not).

As a result, I am obliged to ship all this crap to my office. I have boxes of testing supplies, needles and the rest shipped to work. When those stupid pillow-like containers they put temperature-sensitive items like insulin in arrive, I have to figure out how lug all that crap home on public transit (the subway). I usually toss all the unnecessary packaging (including like my 300th ice-pack, I have more of those than anyone needs, and don't have room in my tiny freezer for any more, so they go directly into the trash -- my, what an efficient "system" mail-order is!). When all is said and done, they take up far less space and make it easier for me to carry home on the subway ride home.

As I already hinted, I pretty much had to order ALL of my scripts by mail-order with this plan (I had a limit of just $250/year in retail pharmacies, mainly for emergency prescriptions for things like antibiotics which patients simply can't wait a week to receive), I knew the drill very well. I also had many other accounts to manage as part of my year-end ritual: HRA, FSA, transit, and I needed to reconcile those. The reason for my doing this is that I've learned over the years that it saves much aggrivation and money. The last thing I need to be dealing with is an unexpected bill for services and NOT being able to expense it because the bill arrived too late to be submitted for reimbursement.
Beyond Medco stuff, I also looked at balances in all of my various healthcare (and transit) accounts. I also had an HRA (health reimbursement account paid for by my emplployer) since my employer subsidized part of my huge deductible (that was a great benefit, but it meant having yet another account that I had to keep track of). And, I had an FSA (again, great benefit, but yet another account for me to keep track of). To top things off, I also had a transit account (again, nice because it enables me to pay for these things using pre-tax dollars reducing my taxible income, but that too was yet another account for me to reconcile and keep track of. Fortunately, my administrator allowed online access to these accounts, so I could login and check out the details without much difficulty. Guess what -- I DID find a discrepancy!

U.S. Leads the World in healthcare (The Third-World, that is)

As it turns out, there was an issue related to services from June 15th, when I saw my endo this summer. I was back to see him in September, so this was a really old claim issue that no one bothered to ask about until I raised the issue with a question. Man, this kind of crap really pisses me off. Anyone who claims the U.S. has a "world-class" healthcare system is in my opinion, an absolute fucking idiot. The U.S. may lead the world in healthcare -- the third world, maybe! I doubt anyone in Europe (Western or Eastern) has to deal with all this payment "he-said, she-said" bullshit, and when interviewed, few would ever want the U.S. system. It just sucks.

In the process, I discovered that my FSA/HRA administrator believed that I owed them $204.40, but when I questioned them on their math, they actually acknowledged that the amount should really have been $172.90 (and they're the ones entrusted to "manage" tens of thousands of healthcare dollars from both my employer and me on MY behalf?! No wonder U.S. healthcare costs are so out-of-control!!). It appears that my insurance company had covered some services from my June 15 endo appointment that the FSA administrator wasn't paid for (since I pay upfront using my HRA/FSA account, and then wait for reimbursement since my endo was out-of-network, although I can expense my co-pays using my FSA), so I called them to figure out whether they were trying to charge it against the wrong account or something (stranger things have happened).

As it turned out, my insurance company supposedly paid for that particular claim, but neither my doctor nor I was the recipient of their payment! So I called my insurance company and after dealing with VRU-hell to finally reach a real, live person (and, they weren't in India, but New York of all places!), I learned that they actually did send 2 checks totalling $172.90, but neither of those checks were ever cashed. I said to the rep "Gee, that just might be a sign the check got lost." I mean, how many recipients, whether it was a doctor, a lab, or a patient would be holding onto a reimbursement check for nearly $200 for 6 months, uncashed? Hello?! Fortunately, this had (has?) a seemingly easy solution.

I told the insurance company "I need you to stop payment on those checks and reissue them both, and mail them to ME" (evidently, they were made payable to me). She did not give me any excuses about how she might not be able to do it for me (which I was expecting), but she cautioned me that it may take 6 weeks for those checks to arrive, which should be in February sometime. I can live with that. I guess my HRA/FSA is going to have to wait for 6 weeks before they get paid, but its no skin off my back, even though all of this is actually MY money, but I had it taken using pre-tax dollars long ago and if I don't use it, it disappears permanently. This is the kind of stuff that makes me wonder precisely what planet all those people who believe and actually claim the U.S. healthcare system is world-class actually live on? The way I see it, the U.S. healthcare system has far too many people with their hands collecting (and skimming something off the top) all this money, but not enough people auditing or actually ensuring that patients really receive quality healthcare. Don't blame patients or doctors, blame all the other layers of "covered entities" (as defined by HIPPA) for that.

Anyway, it looks like when all this billing B.S. is finally resolved, I still had a few extra dollars in my FSA to buy about 6 months of contact lenses and some Dex4 LiquidBlast shots, and because I already had my endo write me "prescription" for those items when I went in September, so I can indeed expense them, but I had to wait until my last two prescriptions of the year were filled via Medco, so the week before Christmas for me involved a lot of shopping, but not for holiday gifts, but FSA-expensible items!

Experience has proven that a few phone calls at the end of the year makes sure I'm not stuck the next year.

As I've lamented a number of times over the years, I work boutique consulting firm, and although I really love the work environment at this company, as a smaller-sized firm with offices in New York and London, the company has been challenged with skyrocketing healthcare costs in the U.S. (it's a non-issue in our U.K. office, which has national healthcare). U.S. insurance companies, as I've discovered, play games that ought to be illegal with low rates to lure new clients in, only to try and double the rates (or more) they charge the following year. As a result, I've literally had about 5 different healthcare (insurance) providers over the last 7 years. I've seen the ugly, the $#!tty and the reason why U.S. healthcare reform was a real necessity for U.S. business: because without it, the U.S. economy simply cannot create quality jobs -- we're likely to produce dozens of jobs that require a paper hat (McJobs, anyone?) or in places like Walmart, but decent jobs, not so much. We're not talking about trying to compete with China (who the hell would want the working conditions those poor workers, many of them children, tolerate?!), we're talking multinational companies choosing to do things like manufacture stuff in places like Canada, Europe or Japan rather than in the U.S. because the liability for healthcare in the U.S. is simply uncompetitive with these places.

Last year, I thought I was certain to join the growing ranks of Americans (Mercer Consulting estimated the percentage around 40%) who have very high-deductible plans without any subsidies from thier employers. In fact, I had been saving in anticipation of this unfortunate reality for much of 2011 knowing what my employer had said was going to be the case in 2012. However, a surprising thing occurred in 2011, namely that my healthcare insurer (one that overwhelmingly serves the City of New York's employees, people like the FDNY, NYPD, teachers in the public school system, City Hall employees, etc.) had decided to stop offering the plan my employer was offering in 2012. The company, which is preparing to de-mutualize itself to become yet another for-profit insurance company (I wasn't exactly in love with this company, but had learned to work within their confines over the past 2 years), stopped offering a plan with out-of-network coverage, so my employer decided to remarket it's healthcare business, extending our coverage with the existing carrier until the end of 2011.

As a result, although our plan year ended officially in August 2011, we remained with the same provider until the end of 2011 while my employer remarketed it's healthcare business. Although so-called insurance "exchanges" mandated by the new healthcare law to be done at the state level should address this starting in 2014, that's still 2 years from now. Even though New York is not among the states that have opted out of the healthcare law (none can opt out of creating the exchanges), small employers are still challenged today to buy healthcare insurance at costs comparable to what large employers can, and the rates of cost increases tend to be in the range of 40% or more PER YEAR.

Anyway, because my employer relies upon professionals with high education levels (our entire staff has a degree of some sort, with more than a few staff members with master's degrees, and even a few doctorates among us), they are acutely aware that they can't get away with Walmart-like benefits and survive. So they actually have a vested business interest seeing healthcare reforms, like insurance exchanges, be launched because they are the very businesses which are being squeezed out of the healthcare market today. Unfortunately, 2014 is a long way off and they have needs TODAY.

The result of the remarketing the company's healthcare business resulted in my employer contracting with what is referred to as a PEO (professional employer organization) to manage various items like benefits, payroll, etc. The biggest benefit is that as a "co-employer", I will be part of a healthcare plan that has over 10,000 "employees" rather than a small company with only 50 or so employees (we also have a few more in our London office, but those employees aren't included as part of the PEO arrangement since they have national healthcare coverage in the U.K. -- in spite of local complaints, it still blows the U.S. system away in terms of long-term patient outcomes AND actual cost according to many studies). Starting January 1, 2012, my healthcare provider officially became United Healthcare. I had United a number of years ago, and although I would never use the term "love" when it comes to any, for-profit healthcare insurance company, my past experience with United Healthcare was pretty positive, especially when compared to WellPoint/Anthem, which I cannot say enough bad things about.

All of this brings me back to the whole Happy New Year theme I began with. In 2012, much of the crap I dealt with with high deductibles, separate HRA, as well as FSA and Transit accounts has been made easier. Now, I can continue to see my own endo, but he'll actually be in-network! This new arrangement also means that the costs of healthcare coverage are unlikely to increase on average 40%-50% every year, as the PEO they've contracted has seen increases in the range of 7% for the last 5 years from what we've been told.

The new arrangement also means that an entire layer of extra bullshit will be eliminated from last year's equation. Another thing I've done when I got my new insurance card was notifying my new pharmacy benefits manager (PBM) United Healthcare uses that I want them to transfer my prescriptions from Medco to (which I believe is also Medco, but it still needs to be transferred) so I don't need to get brand new scripts from my doctor. This way, I was able to start in January when my new insurance plan year begins, I could theoretically fill them on day 1 if I wanted to (I'll wait until the FSA debit card arrives on that). I discovered I could have Rx's transferred from one pharmacy to another last year, when I found Medco's prices for generics to be significantly higher than using, even if I did have to pay the full cost out-of-pocket and the cost did not apply towards my deductible amount, it was still a much a better deal. To facilitate this, the mail-order pharmacy of your new insurance company must contact the old pharmacy and ask them to transfer the scripts to them.

As it turns out, my endo is part of United Healthcare's network, and even the brands of insulin I prefer to use are on their formulary. I may ultimately have to give up my preferred meter (which was my Bayer Contour USB, but I can live with that) for another brand. On the bright side, a Dexcom CGMS may finally be a realistic option for me with the new plan, so apparently the Great One taketh away while simultaneously giving. I'm still figuring out what labs they use. I think they switched to LabCorp, which may be the nation's second largest laboratory (after Qwest), but that company still has relatively few locations where I live, and I've seen the company build new locations all around for the past few years, a process that's likely to continue.

When it comes to test strips, I am of the opinion that these are all pretty undifferentiated commodities. Most testing supplies (except for the Agamatrix/Sanofi system which I'll get to in a second) of the big brands of regular finger-stick meters all use the same basic electrochemical technology.

Hence, few products that have any true points of differentiation, rather they have come to rely on lame marketing gimmicks like coloring the strips blue and using truly unbelievable ploys such as "Double-Sure" technology, which I see as negated and made completely irrelevant by rules of proper testing, namely washing your hands before testing, but hey, it sounds catchy, doesn't it? (Whoever their ad agency is stinks IMHO!), but as noted, that doesn't do much to encourage me to stick with J&J. My endo gave me samples of both the J&J OneTouch Utra meter (I tossed my old one out when I switched to Bayer Countour USB) and Roche Accu-Chek meters since both of them are "preferred" brands on United Healthcare's formulary. I'll sample them both over the next month, and let my endo which one I want to continue with for the next few months.

Who knows, maybe Sanofi's i-Thing (also known as the iBGStar []), which right now only works on Apple's iPhones and iPodTouch devices [I have the latter at least], but hopefully someday Sanofi will come the the realization that Apple's much-beloved iOS only has around 16% of the global SmartPhone market compared to Google's Android which now has over 52% of the market, see HERE) and is growing much more rapidly than Apple's iOS is) might actually be covered by then. Since it has only had European approval for a few weeks, that may be coming before too long. I could always go back to J&J's OneTouch Ultra piece-of-crap for a few months until that happens, after all, I lived with their product before switching meter brands (see HERE), even though there was absolutely nothing I liked about their product which would make me a "loyal" user. I suspect with the Sanofi moves, as well as some smart technology Roche has to help track insulin on board without the use of an insulin pump (see HERE) which is already being sold in the U.K. but is pending FDA approval may someday render the present oligopoly J&J has on the U.S. home diagnostics history in the not-too-distant future unless J&J cleans up their act. Besides, J&J has had an unprecedented number of recalls across the company, raising questions in my mind as to whether it deserves my business. Accu-Chek has a genuine shot this time, although depending on what Sanofi does, I make no guarantees on staying with the brand for the entire year.

Anyway, with that, I'm hopeful 2012 will bring fewer healthcare coverage hassles! Wishing my readers similar hassle-free coverage in 2012.

1 comment:

Jonah said...

Can't say I understood all that insurance stuff.
I believe there is some real difference between brands, in terms of blood sample asked for (meters I could buy at Walgreens go with strips that ask for 0.3 microliters on the low end and 1.5 microliters at the high end), temperature ranges they'll operate in and what they do when you're out of range (one touch meters let you put blood on the strip and count down before giving you an error message; accu chek aviva gives you the thermometer right off the bat), to what extent they are influenced by interfering agents (accu chek aviva strips are still not safe to use if you use maltose containing medications, esp dialyzers, but most us strips are), and overall accuracy and consistancy (accu chek beats one touch).

I like Dexcom. I bought it out of pocket (earlier I bought a Guardian out of pocket) but got insurance coverage for it earlier this year. I do not like some of the sales reps. I like the product plenty but they overvalue it to the point that they devalue my chances of staying alive without it.