I Have Cancer. I Have Insurance. It’s Still Not Enough.
Diseases
Cancer
Issues and Challenges
Paul has encountered: Copay Issues, Insurance Issues, Surprise Billing, Premium Payments
My Story
I have cancer. I have insurance. That should be enough. But no, my insurance and my providers seem to be working together to find loopholes in a system they've designed to look good on paper, but to actually squeeze as much profit out of each patient as possible.
For example, my Blue Shield PPO 73 Silver plan, which costs nearly $1,600/month, has a $0 deductible, but a $6,100 copay max. My in-network doctor office visit copays are as follows: $35 for my primary care doctor and $85 for any specialist. That sounds pretty good, right?
Armed with that information, I made my plan. I need to get opinions from several specialists so I can make a good decision on exactly which cancer treatment is best for me. I budgeted my $85/visit to include about 5-6 visits. The problem is that none of the visits ended up costing $85. They all cost anywhere from 50%-300% more. Why? Because all of the visits took place in an office that for some reason (we know the reason) is connected to a hospital address. Never mind that it was a regular office room like any other walk-in office. Instead, the providers bill extraordinarily high rates and instead of paying the copay, I get hit with a 30% coinsurance based on hospital fees.
I was never informed of these fees by the provider's staff when I called to book the appointments. My beautifully designed Blue Shield Welcome Kit that comes with the neat "Health Plan Guide" pamphlet even lays out the most common services and the charges. There aren't a lot of them. So few, in fact, that there's plenty of EXTRA room on the page to add a line item that could say:
Specialist Office Visit - Outpatient Hospital 30% Coinsurance
Simple, right? Nope... it's not there. What is there is this:
Office visit - primary doctor $35
Office visit - specialist doctor $85
Mental health provider $35
Inpatient hospitalization 30% (coinsurance)
Outpatient surgery 30% (coinsurance)
There's PLENTY of room to add the other items.
I also looked in the Summary of Benefits document, which is a little more elaborate and gives examples of a patient needing an X-Ray or having the flu, etc. Still, no little box for seeing a doctor in their office for a consultation. It's not there. Oh, it's there in a hidden spot not using that type of wording (ask ChatGPT).
I also needed a PSMA PET scan. My summary document clearly states it's a $325 copay. OK, seems a little high considering how much I'm paying in premiums, but OK, the price is right there. Only it isn't. Apparently again, because my test is near or associated with a hospital, there are additional facility fees added. Except, wait... ChatGPT scanned my "Evidence of Coverage" document, which is the 184-page plan laid out with all the fine print. Guess what? It says that a PET scan EVEN IN AN OUTPATIENT HOSPITAL setting is still $325. I showed this to UCLA. They finally agreed and adjusted my estimate to $325. I had the PET scan. A few days later, I got a bill for nearly $3,000. What a surprise! Apparently, they found a loophole where they could bill me for tracers and contrast agents injected into me. That's ALL supposed to be covered since it's just part of the scan.
I've gotten the DMHC involved, although the resolution takes about 30 days. So now I wait.
I have cancer. I have insurance. That should be enough. It's not.
My Motivation and Inspiration
Loopholes aren't illegal, but they're not in the spirit of intention. Blue Shield and UCLA may not be breaking any laws (yet), and I may not win my battle, but clearly this is not right. I'm not the only one going through this, and I haven't started my treatments yet. Right now, I have a LOT of energy. I think this is a fight worth fighting EVEN IF I don't win my battle. I'd like to effect change, and that's why I'm submitting today.
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