You Call this Health Insurance?

If you pay for your own health insurance, as crankyjewishguy (CJG) does, you probably get really cranky once a month when your health insurance premium is due; it's a bill that could easily be confused with the bill for your mortgage payment. CJG pays $1,600 a month for a plan that has $50 co-pays for office visits and a $500 family deductible for prescriptions, but, mercifully, all diagnostic tests are covered at 100%.

If the doctor doesn't charge you for an office visit,
Tufts Health Plan says your $50 office visit co-pay still applies. Huh?

Now, generally, CJG has been pretty happy with his health plan, which is provided by a company that shares a name with a small liberal arts college in Medford, Massachusetts that happens to be where his wife, and two of her siblings went to college, and whose mascot is a stuffed elephant. Oh, OK, it's Tufts Health Plan. But yesterday CJG got into it with Tufts over a reimbursement claim he filed for services rendered to his son, the one who is a sophomore at Harvard on St. Charles, otherwise known as Tulane University. CJG's son is covered for "urgent" care while away at school since no one within a thousand miles of New Orleans is an approved Tufts provider. Urgent care is care that could not be foreseen before the patient left the Tufts coverage area, and so far there's been no problem there. But in early December, CJG's son went to Student Health Services with a bad sore throat and three lab tests were performed and they determined he had strep. The total for the three lab tests was $85.

When CJG got the bill from Tulane, he sent it in with a claim form to Tufts to get reimbursed. The bill listed the three tests and the prices and also included a line that said "Regular Physician Appointment $0." You see, included in tuition are office visits to doctors at the Student Health Center, so CJG had, in effect, already paid that.

Now, two days ago CJG got a check in the mail from Tufts for $35 calculated by taking the $85 in lab work, which is covered in full under CJG's plan, and subtracting $50, the office visit co-pay. So, CJG called Tufts and spoke to a customer representative and a supervisor who insisted that even though the office visit was "billed" at zero, it was still "billed" and the $50 office visit co-pay therefore applied. When CJG pointed out that a "co-pay" means that the insurer, in this case Tufts, has also paid something -- hence the term co-pay -- and in this case they had not because there was no charge for the office visit, they said that's not the way they do it. If it's on the statement, even at $0, the co-pay applies. But on the statement Tufts sent with the check they actually subtracted the $50 on the lines for the lab tests. "That's the way the system works" and "that's they way we have to do it," they said, as if "the system" was set up by some foreign being that has since left the galaxy leaving Tufts with this system they have no choice but to live with exactly as is from now 'till eternity.

Well, bullshit, said CJG. You set up the system and you didn't "have to" set it up that way. You can set it up so that you honor your contractual commitment to pay 100% of all diagnostic tests. If they'd billed $25 for the office visit and done no lab work, by Tufts reasoning CJG would owe Tufts another $25.

Then CJG asked, what if he'd whited out the line for the office visit and sent the bill in, would Tufts have then paid the full $85 for lab work? Yes, they replied. OK, then, CJG will call Tulane and get a bill for the lab work only -- one that doesn't show an office visit billed at zero dollars -- and resubmit the claim which will probably cost you more to process (especially when you include the time we're arguing about this on the phone) than the amount you're trying keep from paying. So, CJG called Tulane and with ten minutes he had a revised bill by e-mail for the lab work only and today he's sending it to Tufts. It'll be interesting to see what happens. This is the kind of bullshit that can drive a cranky jewish guy over the edge, in which case Tufts will be paying for his mental health services.

Perhaps it should say, "no one does more to try and keep your money."

P.S. CJG is on the road again for the next week, this time to California. He can't promise he'll be posting every day. If this causes you anguish or distress, or makes you feel ill in any way, call Tufts Health Plan at 800-462-0224.