Ensurance

A Thanksgiving story for you, as we verge on July. While visiting a friend's house for a group cook-a-thon last November 25, I sliced my finger. It was the index finger of my left hand. The offending instrument was a serrated bread knife in outstanding condition, long and mean. Not uncommon: get a group together, open wine, start cutting; eventually blood will be spilled. In this case the blood was copious, as was the attendant pain. Nonetheless, I wasn't overly concerned. But when the usual home remedies — thorough washing, direct pressure — failed to mitigate either pain or bleeding, and after a quick uncomfortable look at the wound, we decided to drive to a local ER.

This wasn't a decision I labored over. At the time I was covered by a more-than-adequate insurance policy. Deductibles were low. Because it was a COBRA plan, I'd been paying full premiums myself for nearly six months, and they were substantial, and I had yet to use the policy for so much as an aspirin. What was all the expense for if not peace of mind — the knowledge that if and when I did need medical attention, I could easily get it?

The hospital wasn't far from my friend's house in Brooklyn. (It's even closer — 2 blocks — to my own. At the time I viewed this as a pleasant discovery.) We arrived in early evening, around the traditional Thanksgiving dinner hour, and the ER was thus empty. A TV blared in the lounge. A man sprawled over an armchair in a state of restless unconsciousness, ignored by the skeleton crew. I was taken in by the triage nurse, who asked a few clipped questions before hustling me to an exam room.

Here is your first clue: these days, the first thing that happens when you're hustled to an exam room in emergency medicine is that you are visited by the insurance fairy. In my case the insurance fairy was a woman in navy scrubs pushing a loaded cart. Loaded: with computers, I mean, and other unidentified filing and machinery. Not mechanisms of health care in the traditional sense — you need them, yes, but they won't do a damn thing for you by themselves — these are the tools by which the insurance fairy plies her trade, which is verification of coverage. She is spectacularly thorough. I spent no less than twenty minutes going over every possible personal and demographic detail while she patiently, doggedly typed into the top of the cart. There were questions I wouldn't've been asked by a banker (I'd recently applied for a mortgage; I knew). There were questions I was sure my attorney would've advised against. I answered them all. It wasn't that I feared the insurance fairy, exactly — I had insurance, after all. I'd whipped out the card and thrust it at her like van Helsing with his crucifix. But the finger continued to bleed, and to hurt.

And here it's worth noting that, during the insurance fairy's interrogation, no actual medical care was being dispensed. If all you've done is slice a finger, that's not such a big deal. But what if that's not all you've done? What happens if half your head's caved in? I'm sure there's an answer to this, and I'm sure I don't want to ever need to know it. But the fact that the question even occurs should tell you something about just how sick we've become.

I was given a small cup of betadine and told to soak the finger in it. The attending or resident or whatever — the truth is she didn't really say, and I didn't really ask — took a look at the wound. She advised more soaking. A few minutes later she looked at the wound again. This time she told me I could have stitches, or I could try the glue. I'd heard about the glue. I'd heard, for example, that the glue was more or less the same thing as superglue — that it had been developed during the Korean war, or maybe the Vietnam war, for treatment of battlefield injuries. Whatever. It sounded less traumatic than stitches. Let's do the glue, I said; and we did. She glued me together. They sent us home.

That's the uneventful part of the story.

Several weeks later, I recieved a notice from my insurance carrier. The claim — a bill for slightly more than $200 — had been denied, and I would be held responsible. This was, to my way of thinking, given all the checks I'd written, an outrage; and, outraged, I took the statement to the company through which I'd subscribed, and for which I still did freelance work. My understanding, I told the HR director there, was that emergency room visits were fully covered. My understanding was that I shouldn't be paying a thing.

I don't know what I expected; another bureacratic fobbing off, I guess — a reading of the policy fine print in which it was stipulated that yes, emergency visits were covered, EXCEPT, followed by a description of the exact circumstances under which I'd gone. Instead the HR director agreed with me, emphatically. Yes, yes, she said, seeming more outraged still. Absolutely, fully, yes. Phone calls were made. Wheels were set in motion. I'd responded to bureaucracy with bureaucracy, and it seemed, so far, to have worked.

Several days later we got an answer from the carrier. The problem, they said, was that the bill had come from the doctor, not from the hospital. The doctor was not a member of their provider network; the hospital was. Therefore they'd refused to pay.

We — the HR director and myself, now in a Vulcan mindmeld of entitlement — pointed out that, (1), I had entered the hospital emergency room, not the doctor's office, with the intent of (2) seeing whomever happened to be on duty, not of seeing this particular physician or any other. We further pointed out that, (3), the policy provides coverage of out-of-network physicians anyway, just at a higher copay level, so under no circumstances should there have been a complete denial.

They said they'd look into it.

Around this time I got a bill myself, and it was indeed from the doctor. (Who wasn't a doctor, for what it's worth, but an NP — not that under the circumstances it really matters.) I took it in to the HR director. Yes, yes, everyone said. Now we've got it. It's the hospital's fault. Because we haven't yet received a bill from them, we can't verify it as a legitimate emergency room visit; thus we can't pay. We'll just have to wait for the hospital to issue their bill. Then the doctor's bill will be legitimate, and all will fall into place.

It's yet another sign of cultural illness and decay that this made, in some warped, bureaucratic, utterly logicless way, a kind of sense. But it did. And so we sat back to wait.

Weeks passed. Having set the various corporate chains in motion, I assumed the engine would eventually reach speed. Surely the hospital wanted to get paid, and so surely they'd send a bill. But I am also a cynical type, and I began, as such, to wonder several things. Was it possible the doctors were engaged in some kind of side-billing scam, for example? Hoping, I mean, that I would simply pay the denied claim at face value, thus sparing them the insurance company's negotiation? Or had the hospital, for similar reasons, worked out some kind of weird subcontractor relationship with the physicians, leasing facilities rather than employing them outright, to diffuse responsibility and costs? Just what new twist in the already byzantine dance of American healthcare was this?

The insurance rep, by his own account — which seemed genuine — made multiple attempts to reach the hospital with requests for their bill. For weeks, neither calls nor emails were returned. Finally he got through, and reported that the bill had been sent; the claim would be resubmitted; and he had marked it to be paid. A week or two after this I received another statement from the insurance company; this time, the claim, it reported, had been paid in full. This notice was dated May 6, 2005 — not quite six months after the inury itself, and the superglue that fixed it.

All's well that ends well, yes? And so I thought. Yet just this week, two more pieces of mail on the subject of my hacked finger (which has healed, but uglily; and the nerves are askew to this day). The first was a letter from an attorney, demanding payment for the doctor's bill that had been denied so long ago. The attorney's letter was dated May 29, a full three weeks after all contention had ceased and the check had, presumably, been sent. I replied with a copy of the insurance statement. This might or might not take care of it. It won't surprise me if there are more letters to be exchanged, more representatives whose opinions must be sought, more threats to trade before everyone agrees to call it done.

But the last was worst. There was yet a third Explanation of Benefits statement from the insurance company; in this one, I was informed I'd have to pay a $50 deductible. More shocking, though, was everything else on the statement — all the stuff I wasn't having to pay for because the insurance company was. There were four line items, ranging in associated cost from $60 to $400. The total bill was $897.00. All line items were marked with the hospital's name and "Specialty Room." That's it; no variation, just "Specialty Room," four times, and next to each an amount. This meant that, with the previous bill, the total charge for my visit was more than $1,100.00.

This was stupefying. It had to be, I figured, a mistake, or — worse? better? just different? — a scam. I'd been there thirty minutes, maybe forty-five if you included the perfunctory triage interview and the insurance fairy's visit. The skill level involved in every step was minimal, by medical standards or any others: a student could have treated me in exactly the same way, in the same amount of time. A gym teacher could have, almost. The most sophisticated equipment deploying during the entire episode was that on the insurance fairy's cart. There were no x-rays, no ultrasounds, no CAT scans or MRIs. There was scarcely any palpitation. She took a couple of long glances and shifted some skin around — with her fingers. Supplies-wise, we used 1 plastic cup; about 1/4 cup of betadine; four or five drops of the glue; some gauze, and assorted dressings and bandages. Dinner at Otto uses greater amounts of more expensive stuff.

I called the insurance company immediately. They'd been snowed, I figured. I would do them a favor. I would let them know what had really gone down. I would do my part to rein in the spiraling costs of US healthcare.

You know what happened next. It has probably happened to you. Statistically speaking, it must have happened to some of you. The woman on the other end of the line — my ally, I'd expected — received my indignant whistleblowing as though I'd come over the line in Martian.

Do you realize this was a trivial thing? I asked, my incredulousness running over.

Oh, yes, she replied.

Do you realize the total amount they're charging for this trivial thing?

Oh, yes. They do that all the time.

This is normal?

Oh yes.

For something like this — to cost so much?

Oh yes.

They bill you for the doctor, she said, and they bill you for the room, and they bill you for the equipment and the supplies. They bill you for everything. It adds up.

This is, I said, the most ridiculous thing I've ever seen in my life.

Is there anything else I can do for you today? she said.

There was not.

It's funny. Except that it's not funny. It's what passes for your healthcare system. It has severed all ties to reason; even to call it a "system" implies logic, and that's nearly impossible to uncover in such a mess. It costs more than any comparable system on the face of the earth and its efficiencies dwindle every day. How could they not, when an episode like this is not an exception but the norm? Forget about where the money's going; let's assume it's going several places. Let's assume there's not just one set of pockets being lined by all that cash but a number of them, in several professions and industries. The drug companies. The equipment manufacturers. The administrators of the corporations that own the hospitals, and the administrators of the corporations that insure us. Does it make any difference? We currently have forty million uninsured in this nation, many of them children; the number does not decrease every year, ladies and gentlemen, it increases. Soon we'll have fifty million, and after that sixty million, seventy, a hundred. That's one in three. Things are getting worse. And no one is doing anything about it. It is, to borrow a phrase from the Republicans who adore this so-called system, and who defend it nearly with their lives, and certainly with their pocketbooks (which it has, of course, considerably fattened), a moral outrage.

The nature of that outrage is a subject for other, deeper, angrier and even more confusing meditations. In the meantime, if you happen to slice your finger, consider the following regimen: wash it in cold running water ($0). Apply direct pressure with some sterile gauze ($3.99), and keep the hand elevated above the level of your heart to help ease the flow of blood ($0 — and yes, it's quite possible this is an old wives' tale. Your guess is as good as mine). Once the bleeding has abated, rinse it with some hydrogen peroxide ($0.99) and clean the nearby surfaces with rubbing alcohol (also $0.99). Attach the separate ends with a butterfly bandage ($4.99), or, if you're really feeling the need, with an over-the-counter version of the medical glue, which you'll find these days right next to the bandaids at your local pharmacy ($9.99). Wrap the whole business in more sterile gauze (from the same package as before, so $0), and/or put some appropriately sized bandaids around it, tightly but not so tightly you cut off circulation. Change dressings every day, twice a day if you need to, and avoid getting it wet for a week or two (wrap a plastic bag — $2.29 — around your hand if it helps, and seal it with a not-too-tight rubber band). Of course I'm not a doctor or an NP, or any other kind of licensed medical practitioner, so I can't charge you for this list; I also can't guarantee it will work. You'll have to attempt at your own risk. But then, there'd be no guarantees if you went to the hospital and they told you pretty much the same thing. And the bill in that case would be approximately $1025.00 more.