Krazy Like a Fox

Sometimes things happen which seem out of our control. They sneak up and invade our lives, causing us to question our own sanity. That happens to me all the time, because it seems I am a magnet for weird and unexplainable occurrences.

For example, I got a call the other day to confirm an appointment I have next week for a medical test (routine, preventative care). The person on the other end of the line was very nice and explained to me the way my health benefits work and how that would affect the amount I was required to pay. Since I have a plan with a deductible and coinsurance, those amounts have to be met before the insurance company has to kick in their share. I totally understood, and I knew that my plan covered mammograms 100% with no out-of-pocket, so I wasn’t worried.

Let me give a little background, though, before I continue. Thirteen years ago my mom passed away. Five years prior she had been diagnosed with breast cancer. That automatically placed my sister and me in a high-risk group.

What I learned since that time is there are different types of mammograms. There is the garden-variety, routine type that all women should start getting at a certain age. This is called a screening mammogram. It’s apparently not good enough for someone in “high-risk”, so there is another procedure called a diagnostic mammogram. That’s the one I need, in combination with an ultrasound. It is what I have always done, and thanks to health insurance, I’ve never had to pay before. After all a mammogram is a mammogram and the basic purpose is the same for me as it would be for any other woman: prevention.

Welcome to the new age of group health coverage. Diagnostic mammograms are billed using different medical procedure codes and this gave insurers a great opportunity to exclude them from being categorized as preventative care.

Thank you Cigna for sending me all of the pamphlets stating that routine preventative care is covered at 100%, as long as I go for my yearly check-up with an in-network provider. What they forgot to print on the brochure was “Except you, and you know who you are”.

That would be me, in case you were wondering.

Anyway, back to the phone call. After all of the calculations of procedure cost, deductibles and any other mumbo-jumbo, I was informed that my out-of-pocket cost for the visit would be $645. My response of course was that of shock, and the young lady on the phone realized she wasn’t getting anywhere by offering me various payment plans. So, she explained one more choice. If I pay for the visit myself without using insurance coverage the cost is $395. What else could I do at that moment but call the customer service line at Cigna and inquire why my insurance, for which money is deducted out of every one of my paychecks, would charge me more for a medical service than it actually even costs?

Ten minutes later, I heard myself saying to the Cigna Customer Service Rep: “So, you are confirming that it is better for me to pay for this service myself, rather than use the coverage that I have already paid for in 24 bi-weekly payments so far this year?” His answer was yes, of course, because $645 > $395.

I could not believe this was happening. And forget the fact that mammograms are usually covered by insurance companies, I assume because it is more cost effective for them to try and prevent breast cancer than it is to pay for the treatment therein.

Except for someone who is at a higher risk, right? Um, no, that doesn’t make sense.

Am I being penalized because they think even if they pay for my yearly screenings, I’ll still end up getting sick and costing them a lot of money? No, that seems too shady, even for health insurance executives.

So then why? And furthermore, how is it allowed?

I pondered those questions for a few days, and I still have no idea.

But you can bet I’m going to keep trying to find out.

I’d have to be krazy not to.

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One thought on “Krazy Like a Fox

  1. There is only one reason you are having an insurance disaster now; and, believe me I understand. The one reason is “Obama Care”. It has F?#%$& up the entire coverage industry. Good luck!

    Like

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