Dear Blue Cross PPO, you suck

For the last, oh say, five years–since I stopped working full time for the previously mentioned in past blogs giant soul-sucking pharmaceutical company–we have had to pay for our own health insurance. So instead of paying about $100 per month to cover my whole family (four of us) with a pretty good PPO plan, we now pay–wait for it–about $2,400. Fucking shocking, I know.

We chose a plan that would cover us with those pesky little “pre-existing conditions” like my migraines, my husband’s barely elevated blood pressure and cholesterol (like many middle-aged men in America, right? To call that a pre-existing condition, well, don’t even get me started.) JP also covers his brother who “works” for him (again, let’s just not even go there), but his coverage is barely even basic and works as a write-off for him and the business. However, we still have to come up with the money each month.

So, what’s my point?

In the past year, I found a dynamite neurologist here in the OC, Kennth Martinez, MD (www.thebrainpro.com) who realized that part of the reason for my migraines is intense tightening of my neck muscles, called cervical dystonia or torticollis (literally means twisted neck). Kind of like muscle spasms that don’t go away. He can inject Botox at the site (or sites in my case) of the spasms and wah-la–headaches gone, tightening gone = RELIEF. Dystonia is an FDA-approved indication for Botox. Migraines are not. Are you with me so far?

So, the billing gals at Dr. Martinez office are whizzes at getting Botox approved–he specializes in all kinds of neurological diseases and uses it frequently to relieve people’s pain. They submitted a “prior auth” (oh God, the dreaded prior auth–I thought I had removed that phrase from my vocabulary once I left the previously mentioned in past blogs soul-sucking vocation of pharma rep, but NOOOO) and got the pre-approval. Yes! I go in, get my injections, yay. It’s all good. This is LAST NOVEMBER.

Or so I thought.

When I go back four or so months later for the next one, Lydia in billing tells me that Blue Cross hasn’t paid yet on the first injection. Uh-oh. No worries, she says. This is quite common with them. We’ll just keep resubmitting. (Can you see where this is going?) They went ahead and did another injection in, let’s see, February. Ah, blessed relief. And another one in, hmmm, June. (I love that they are willing to inject patients while still dealing with these blasted insurance companies. They rock.)

Still, nothing.

Finally, though I am due for my next injections, they cut me off. Blue Cross has paid them NOTHING. Has DENIED all claims as experimental. WHAT? It’s an approved indication! Yes, they know. They have submitted all the paperwork to appeal it. So I get on up on my high horse and call the insurance company myself.

And this is where it goes into the surreal.

I talk to Yolanda. She tells me that no, they did pay out. For the November bill of $2500 (just so you know, we’re talking A LOT of Botox), they paid out .76 cents. So, it’s been paid. Yea, you read that right.

I was like, whoa, chickadee. You are not laughing here, so I assume you are serious in telling me that your company considers this paid, correct? That is correct, ma’am. (oh, no, here we go with the ma’ams again.) All .76 cents of it? That’s considered paid? Yes, that’s right, ma’am. Oh, okay, my bad.

Wow. So, let me see if I understand this correctly, Yolanda. I pay, on a monthly basis, to your company BLUE CROSS OF CA PPO, what just one of these treatments costs. $2,400. (This does not include prescriptions or deductible-that’s extra. Of course it is.) Multiply that times twelve months and that’s…$28,800. Correct? Yes ma’am. I believe, Yolanda, that what I pay for is called COVERAGE, yes? Yes, ma’am. Well, correct me if I’m wrong, but do you see any coverage happening here?

Well, I got a long song and dance about how the billing girls at Dr. Martinez’ never submitted it to appeals, blah blah blah which is of course total B.S. because I checked with Lydia who of course emailed me the plethora of forms on all this and she’s done beyond and we figure they are just jacking us around. Of course they are. It’s in their best interests not to pay.

I should be grateful, lucky I even have insurance, though, right? See, that’s the racket right there. You pay all this money, a fortune! And this is what you get–and somehow I’m supposed to be sooo grateful for it.

Well, you suck Blue Cross PPO and I hate you. So there. I’m crushing your head.