Health Insurance

I am an employee of the State of Texas.  Until most recently, the State of Texas contracted with Blue Cross and Blue Shield of Texas to provide health care coverage to its employees.  September of 2012, that changed, and we are now covered by United Health Care.  So many people say that United Health Care is an inferior health insurance provider.  Especially medical providers: they negotiated lower rates of pay than many other insurance providers.  But these negotiations were widely although not universally accepted.  And the State of Texas changed to this insurance provider for the lowered costs.

There have been some things that for me are good about this new coverage.  Wellness prevention checks are covered.  For years, my major medical expense was the co-pay for my yearly gynecological exam.  Now, there is no co-pay.  I have had to have some x-rays this past year, and there has been no co-pay for some of these, as they were preventive, not diagnostic.

I am careful to use my insurance as I am supposed to:  My primary care physician is excellent at following up on getting referrals and authorizations. I check that these have been obtained, and I try to make sure I understand what the parameters of these authorizations are.

I needed new glasses and went in for a vision exam.  The optometrist discovered some problem with my left eye, and he suspected it was with the optical nerve.  My PCP obtained authorization for follow up appointments, and I went to that appointment. 

Recently, I received an explanation of benefits from the insurance, which indicated that the optometrist was "out of network."  Well, when I checked the list of "network" optometrists, he was still listed, as he had been when I went for that appointment.

So, I called the insurance company to find out what was going on. The wonderfully understanding representative assured me that I had a valid authorization and referral. She quickly ascertained that the problem was that the optometrist billed under an ID number that was not a current provider number with the insurance.  She said that if I have to have additional follow up, WE  need to find me a new provider who will be covered for this problem. The insurance representative asked me if she could put me on hold, called the optometrist office, and then got back to me. She told me with whom she spoke.  She said that the office person said they thought, including the optometrist thought, that he was authorized with the insurance as a provider, and that they would correct that. The insurance representative said that if they did correct that, they could retroactively submit my bill as a courtesy, so I would not have to pay the uninsured bill.  She also told me to check back with the provider in a week or so, to make sure that they follow through. 

I had dreaded contacting the insurance. I was pleasantly surprised by the customer service that I received.  I do not know how this will be resolved. I have little faith that the optometrist and his clerical staff will do the right thing.  I am sure I need to find a new optic provider: probably an opthamologist, since I know I have cataracts, and now possibly some other problems.

This was a good lesson regarding health insurance.  I know no matter what authorizations there are, there are no guarantees. 

I was pleasantly surprised by the help from the insurance company. I hope this can be resolved in my favor, but I am anticipating a protracted negotiation, which I hate, but which I suspect I will have to negotiate.

Well, this is true. There are no guarantees in life So why should I think there are guarantees in insurance.