"Health" Insurance
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Thread Starter
Join Date: Oct 2007
Posts: 17
"Health" Insurance
Blow is my post to a blog I just created. It gives the basic details of what I'm dealing with. I'd be interested in hearing if other people have run into similar situations and/or have advice for me both regarding treatment and addressing the insurance issue.
Drug addiction is a scary dark world for the addict. Trying to get help through the managed care system is even scarier. I'm not an actuary so I don't know exactly how Blue Cross Blue Shield determines it's policies but the following is apparent: some number-cruncher at BCBS has divined that providing proper substance abuse treatment for it's members is too financially risky. Common sense suggests otherwise - wouldn't ongoing treatment for liver disease or rehabilitation after a drunken car accident be more costly than preventing these very likely events?
Here's the story. A good friend of mine, Erin (not her real name), has had a drug and alcohol addiction for two decades. Not a debilitating addiction - she has a very well paying job, is a great mother and a loving friend. Erin is not the corner crack-head that the word 'addict' conjures for most people. The sad fact is that I bet there are more Erin's in the world than back-ally addicts. Think about that, these are the people driving next to you on the highway.
Recently her alcohol dependence worsened and intervention was a necessity. She recognized her problem and drove 5 hours to an inpatient treatment facility - this is a person committed to recovery but in need of professional assistance to get there. After 3 days there BCBS determined that she was all better and they denied her claim for further treatment. They made this determination by asking her doctor if her vital signs were stable and concluded that further treatment was not medically necessary. Not medically necessary, but her doctor refused to discharge her because she wasn't fit to reenter society. So she was forced to stay for an additional 3 days at $1300/day. Now $1300 a day seems a bit ridiculous to me but I'll address that in another post.
So here's a sick person looking for help, asking her insurance company to cover up to 30 days inpatient treatment as her policy allows for, and she's told to fend for herself. After an appeal for a 2nd look at the claim (which was promptly denied) we decided to focus on getting her the care she needs. BCBS will not cover intensive outpatient service, such as day programs. They will only cover 20 one hour therapy sessions.
My present goal is to help her find appropriate treatment. Once that's accomplished the insurance issue is going to be addressed in a big way. This blog will serve to chronicle that process.
Here's the story. A good friend of mine, Erin (not her real name), has had a drug and alcohol addiction for two decades. Not a debilitating addiction - she has a very well paying job, is a great mother and a loving friend. Erin is not the corner crack-head that the word 'addict' conjures for most people. The sad fact is that I bet there are more Erin's in the world than back-ally addicts. Think about that, these are the people driving next to you on the highway.
Recently her alcohol dependence worsened and intervention was a necessity. She recognized her problem and drove 5 hours to an inpatient treatment facility - this is a person committed to recovery but in need of professional assistance to get there. After 3 days there BCBS determined that she was all better and they denied her claim for further treatment. They made this determination by asking her doctor if her vital signs were stable and concluded that further treatment was not medically necessary. Not medically necessary, but her doctor refused to discharge her because she wasn't fit to reenter society. So she was forced to stay for an additional 3 days at $1300/day. Now $1300 a day seems a bit ridiculous to me but I'll address that in another post.
So here's a sick person looking for help, asking her insurance company to cover up to 30 days inpatient treatment as her policy allows for, and she's told to fend for herself. After an appeal for a 2nd look at the claim (which was promptly denied) we decided to focus on getting her the care she needs. BCBS will not cover intensive outpatient service, such as day programs. They will only cover 20 one hour therapy sessions.
My present goal is to help her find appropriate treatment. Once that's accomplished the insurance issue is going to be addressed in a big way. This blog will serve to chronicle that process.
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Join Date: Apr 2006
Location: OHIO
Posts: 959
Hmmmm...welcome here and I understand the dilemma...I was married to a very high functioning alcoholic for 22 yrs and we also had BCBS. He never addressed his disease like your friend but you mention that she has a very high paying job right? So whats the problem?? She can afford the treatment. JMHO
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Thread Starter
Join Date: Oct 2007
Posts: 17
Two problems with her paying her own way: 1. she's been given 30 days leave without pay to address her problem. 2. yes, she makes good money but non of it is disposable. Many people with big pay checks generally have big bills to match.
Member
Join Date: Apr 2006
Location: OHIO
Posts: 959
Well until the system catches up with the needs of the policy holders....her only avenue may be to liquidate an asset so as to accomodate the impending medical bill. I wish it would be easier for her and for all....as I understand her dilemma. I hope she is able to get the help she is much need of hun...she truly has a good friend in you.
get it, give it, grow in it
Join Date: May 2007
Location: Calif coast
Posts: 3,167
My son went to a primary recovery program of 4 wks paid by Blue Cross-tho it took many many phone calls and they only approved a week at a time The number of facilities on their approved list was minimal. The next rehab I footed the bill.
the best programs ususally are out of pocket and as you know aren't cheap.
If she can liquidate something to pay for good treatment then she should because addiction will destroy her life and she only has one life to live.
That is the reality of rehab in this country. THAT said, people that are ready to recover can do it for free and many have by walking into AA/NA mtgs and keep working that program. If she goes into AA and doesn't like it they will refund her misery. Bless you for trying to help but be carefull not to take on too much ownership
the best programs ususally are out of pocket and as you know aren't cheap.
If she can liquidate something to pay for good treatment then she should because addiction will destroy her life and she only has one life to live.
That is the reality of rehab in this country. THAT said, people that are ready to recover can do it for free and many have by walking into AA/NA mtgs and keep working that program. If she goes into AA and doesn't like it they will refund her misery. Bless you for trying to help but be carefull not to take on too much ownership
Member
Join Date: May 2004
Location: England
Posts: 3,410
AA - I bet she could fit in a lot of meetings in 30 days.
Salvation Army - free and willing to help
SMART - online 24/7
RR
SR - 24/7
Therapy
Alan Carr
Self - spontaneous remission is most common, yet those guys sneak under the radar because they never come close to being "measured".
I get really frustrated by this belief that inpatient rehab is the only way to adress issues. You only have to read on SR that expensive rehabs etc are not necessarily the answer. The answer is inside. There is a whole industry out there ready to take cash from insurance companies or those willing to re-mortgage their property. Why must we perpetuate the belief that 30 day rehab is what is needed?
Salvation Army - free and willing to help
SMART - online 24/7
RR
SR - 24/7
Therapy
Alan Carr
Self - spontaneous remission is most common, yet those guys sneak under the radar because they never come close to being "measured".
I get really frustrated by this belief that inpatient rehab is the only way to adress issues. You only have to read on SR that expensive rehabs etc are not necessarily the answer. The answer is inside. There is a whole industry out there ready to take cash from insurance companies or those willing to re-mortgage their property. Why must we perpetuate the belief that 30 day rehab is what is needed?
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Join Date: Jun 2007
Location: Arlington, VA
Posts: 4,290
Its good that she's decided she wants to work on beating her addicitions. Now she needs to find the way that will work for her that she is willing to invest in. The only really necessary investment is time and committment. Inpatient rehab is nice but not required . If that is the route she wants to take, then its sounds like she will have to make the investment in herself by selling an asset or 2.
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Join Date: Sep 2005
Location: Lost in NC
Posts: 416
I ran into the same situation with my X. BCBS helped pay for 20 days of inpatient service, And that was with the facility having to fight weekly with them to keep her there. She was by no means ready to leave, but....I not sure anyone or place could have helped her.......she did not want to get better!
I do not know what the answer is............I know its not "Hillary Care" The health care industry in our country is our largest business sector. (I heard around 330 Billion dollars annually, larger than the GDP of China!) It can't be run from a centralized location or by the likes of all those in D.C.
But when the middle class can no longer afford health care, or are bankrupted when a family member becomes ill.............something has to change!!!
I do not know what the answer is............I know its not "Hillary Care" The health care industry in our country is our largest business sector. (I heard around 330 Billion dollars annually, larger than the GDP of China!) It can't be run from a centralized location or by the likes of all those in D.C.
But when the middle class can no longer afford health care, or are bankrupted when a family member becomes ill.............something has to change!!!
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Thread Starter
Join Date: Oct 2007
Posts: 17
Originally Posted by guyinNC 
something has to change!!!
For the record, I am quite aware that a 30 day inpatient program isn't always necessary and may be less beneficial than outpatient or community based support. The issue here is that her doctor said she wasn't ready to leave and insurance denied the claim anyway. Her own doctor who was trying to treat her was second-guessed by someone 500 miles away in an office building.
I'm talking about dropping a vulnerable, confused and drugged-up (by the way) girl on the street. She will make it because she's committed, but what about all the other people in the same situation who don't have the support system that Erin has? The people who really need more than a 3 day detox to get their head straight.
I know that a person cannot be helped if they don't want to be helped. I know that there are free programs that can be very beneficial, but let's not loose sight of the fact that the healthcare system is failing so many people.
The people in the clinic Erin was in who had Medicaid get to stay and be treated. Those with private insurance are kicked out after 3 days in a 5 day detox regimen. You can use scary words like "socialized medicine" till the cows come home, but the reality is that people on our current socialized healthcare system (medicare & medicaid) get better treatment than those with private insurance in many cases.
Member
Join Date: Jun 2007
Location: Arlington, VA
Posts: 4,290
Insurance companies are in the business of making sure patients use as little of their benefits as possible. Patients are shoved out of all sorts of hospitals for all sorts of conditions earlier than used to be the norm. As long as the isurance business is a for profit system, it will not change.
Acting not reacting
Join Date: Jun 2004
Location: My happy place
Posts: 1,788
Its real interesting to me how the health insurance industry is assasinated on a regular basis, for a persons substance abuse.
Its not the insurance companies fault that someone is an addict anymore than it is mine.
Insurance companies are not non-profit and they are in the business for profit. That coupled with the fact that benefits as part of a group policy (aka coverage through ones job, premiums paid by employer) are defined by what the employer chooses to pay for. I do not live in Canada and the US doesn have socialized medicine. Another example of it is what it is and accepting things as they are (not what I want them to be) or making changes in MY life to find it more acceptable.
I am not a big fan of my group coverage, but its a choice like everything else. If I want other insurance, I should find a way to get it.
Its not the insurance companies fault that someone is an addict anymore than it is mine.
Insurance companies are not non-profit and they are in the business for profit. That coupled with the fact that benefits as part of a group policy (aka coverage through ones job, premiums paid by employer) are defined by what the employer chooses to pay for. I do not live in Canada and the US doesn have socialized medicine. Another example of it is what it is and accepting things as they are (not what I want them to be) or making changes in MY life to find it more acceptable.
I am not a big fan of my group coverage, but its a choice like everything else. If I want other insurance, I should find a way to get it.
Becoming a Butterfly
Join Date: Jun 2006
Location: New York, NY
Posts: 904
China's GDP is over $10 trillion. And the most profitable US companies are exxon, walmart, Ford, Chevron, and GM. Not a healthcare company in sight.
I have no idea if Hillary Clinton's plan will work or not, but someone has to do something and I applaud her for being brave enough to step forward and offer to take action.
I have no idea if Hillary Clinton's plan will work or not, but someone has to do something and I applaud her for being brave enough to step forward and offer to take action.
Originally Posted by guyinNC
I ran into the same situation with my X. BCBS helped pay for 20 days of inpatient service, And that was with the facility having to fight weekly with them to keep her there. She was by no means ready to leave, but....I not sure anyone or place could have helped her.......she did not want to get better!
I do not know what the answer is............I know its not "Hillary Care" The health care industry in our country is our largest business sector. (I heard around 330 Billion dollars annually, larger than the GDP of China!) It can't be run from a centralized location or by the likes of all those in D.C.
But when the middle class can no longer afford health care, or are bankrupted when a family member becomes ill.............something has to change!!!
I do not know what the answer is............I know its not "Hillary Care" The health care industry in our country is our largest business sector. (I heard around 330 Billion dollars annually, larger than the GDP of China!) It can't be run from a centralized location or by the likes of all those in D.C.
But when the middle class can no longer afford health care, or are bankrupted when a family member becomes ill.............something has to change!!!
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Join Date: Jul 2004
Location: Starting over all over again
Posts: 4,426
Hey gang, wonderful thread so far.
I have my own axe to grind with the healthcare system, but I'll save it for the "cafe". Can we get back to the original posters questions?
thanx
Mike
I have my own axe to grind with the healthcare system, but I'll save it for the "cafe". Can we get back to the original posters questions?
thanx
Mike
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Join Date: Sep 2005
Location: Lost in NC
Posts: 416
My reference was to the whole health care industry, not one particular company. This segment of our economy is equivalent to China’s GDP. (My original number was too small.)
Total U.S. health care expenditures are projected to increase from $2.17 trillion in 2006 to $2.88 trillion in 2010, with annual increases averaging about 7%.
The health care market in the U.S. in 2006 was made up of hospitals ($662.5 billion), physician and clinical services ($463.3 billion), prescription drugs ($219.2 billion), nursing home and home health ($181.5 billion), and other items totaling $549.2 billion.
http://www.plunkettresearch.com/Indu...3/Default.aspx
China's gross domestic product (GDP) totaled 20.9407 trillion yuan (US$2.7 trillion) in 2006, up 10.7 percent year on year, according to latest figures provided by the National Bureau of Statistics (NBS) Thursday.
Total U.S. health care expenditures are projected to increase from $2.17 trillion in 2006 to $2.88 trillion in 2010, with annual increases averaging about 7%.
The health care market in the U.S. in 2006 was made up of hospitals ($662.5 billion), physician and clinical services ($463.3 billion), prescription drugs ($219.2 billion), nursing home and home health ($181.5 billion), and other items totaling $549.2 billion.
http://www.plunkettresearch.com/Indu...3/Default.aspx
China's gross domestic product (GDP) totaled 20.9407 trillion yuan (US$2.7 trillion) in 2006, up 10.7 percent year on year, according to latest figures provided by the National Bureau of Statistics (NBS) Thursday.
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