My wife had oral surgery last week. She got a prescription for a common painkiller to help with the recovery. The prescription ran out and she needed a refill.
That's when things got -- interesting.
I'm an IT contractor. When I'm working, I'm insured. I generally let my insurance lapse when I'm between gigs. Yeah, it's risky, I know. But my wife is on Medicare, parts A, B, and the newest: Medicare D, the drug benefit run by our glorious, best-care-in-the world private insurance industry. So I'm never worried about her. Right?
My job ended in mid June. I could have worked longer, but I was just going to work doing absolutely nothing all day (which I hate with a passion) so I laid myself off. Better for me, better for the company. My last day of benefit coverage was the last day of my last working month, i.e., June 30.
My wife's surgery was on June 29, outpatient, no big deal. Not covered by dental, which we knew going in, so we paid out of pocket. The prescriptions were covered as usual.
The prescription ran out over the long 4th of July weekend, so she called in early Monday to her oral surgeon to approve the refill, which he did right away, and called it into our pharmacy. She was in bed, in pain, so I drove over to get it.
They had the drug, and they filled the prescription. But oh, by the way: your insurance coverage has been denied. Please pay the full amount, $13.58.
Huh? What? Denied? How can that be? My wife is on Medicare D. They take the payments right out of her social security, so we never miss a payment. This is, after all, the best system in the world! They keep telling us that, so it must be true.
I fished in my wallet and found my wife's Medicare D drug insurance card, issued by her insurer, Humana. A bit irate, I waved it in the face of the hapless pharmacist. See? She's covered!
Okay, okay, no need to wave that card, sir. We'll call it in again. Please wait.
A long wait ... pharmacists on the phone. I'm wandering around the store, window shopping. Eventually, they get back to me. And the story turns out to be this. When I was working, I had Blue Cross medical, and I covered my wife, just to make sure. Blue Cross's coverage was a little better in some respects than Medicare and I figured, why not.
But Humana found out that my wife was covered by Blue Cross, and they set a flag on her record that said: coverage will be paid by primary care provider, i.e., Blue Cross. Then Blue Cross went away, but the flag on my wife's record stayed put. So Humana said: Blue Cross pays. And Blue Cross said: no we don't. Result: coverage denied.
Your multiple-payer system at work. Or, to be more precise, at not working.
The pharmacist was surprisingly sympathetic, considering that I had chewed his head off earlier. He gave me an 800 number to call: Humana Customer Service.
So ... to the phones again!
Another long wait. But finally I talked to a real person at Humana Customer Service. You're denying my wife's coverage, I said. Please pay it.
Do you have other insurance? she asked.
Not any more, I said.
Oh, there's a problem with the premium? she asked.
No. The premium is automatically deducted from her Social Security. We've been paying you. Now it's time for you to pony up.
Hang on, she said. Another loooong wait.
Yes, she said. I see you're covered by Blue Cross.
(*#&$(*&!!
No, we're NOT covered by Blue Cross any more. We are covered by YOU, Humana. Your records are in error. Now fix your records and pay the damned claim.
I see, she said. Please hang on.
Another loooooong wait.
Mr. Pickering? Everything is fine now. If you run the claim again, it should go through.
**********************************************
So they ran the claim again, and it went through. The final bill had been reduced from $13.58 to a $5 copay. The pharmacist was on the phone twice, once to Blue Cross and once to Humana. I was on the phone once in one long call to Humana. The entire episode took about an hour. During that hour, the pharmacist wasted his time, I wasted my time, the people at Blue Cross wasted their time, all because Humana was trying to save $8.58 which they ended up paying anyway. And that's not even counting the cost for the offices and salaries of all those people Humana hires to shift the cost over to Blue Cross, and the people Blue Cross hires to shift the cost back to Humana.
You want to know why our health insurance costs so much? You want to know why single payer is the best option? Take this incident. And multiply it by 250 million insured Americans.
That's why.