Beliefnet
Beyond Blue

Producer Michael Moore could have used my conversation this afternoon with a CareFirst representative for his documentary “Sicko“:
Me: “I just want to know why I received an explanation of benefits 18 months ago that said the patient responsibility was zero, and now all of a sudden I have to pay $2,600.”
CF: “All the medical documentation was not in place at the time we sent you the earlier explanation. They had to readjust the figures once the paperwork was in.”
Me: “The medical documentation took two years to get?”
CF: “That’s correct, ma’am.”
Me: “But this is the first time I’ve heard about your policy stipulating 85 percent coverage for the first through the sixth visit, 65 percent for the sixth through the 30th, and 50 percent coverage for all visits after that. The nurses running the outpatient program told me explicitly that I was covered in full for all days I was there. They talked to a representative at CareFirst who confirmed full coverage at that time. In fact, I have a letter from Magellan–your mental health partner–stating that my treatment was authorized and would be covered under its plan.”
CF: “You were authorized, but that doesn’t mean we promised to cover it fully.”
Me: “I asked the nurse six times if she was sure you guys would cover my treatment. After she hung up from speaking to a CareFirst representative, she put her arm on my shoulder and said, ‘I would not have admitted you to the program, and I wouldn’t have allowed you to stay, if I wasn’t sure it would be covered in full.'”
CF: “I’m sorry, Ma’am. I’m just explaining our policy.”


Me: “But I have two explanations of benefits that have a fat zero next to the words ‘patient responsibility’…. So, let me get this straight, you’re saying that my 45-minute counseling sessions prior to the hospital program used up the entire 30 days of coverage at 85 or 65 percent, and so all my hospitalization is billed at 50 percent?”
CF: “That’s correct, Ma’am.”
Me: “So eight hours at a hospital–including intensive group therapy with at least three nurses and an individual appointment with a psychiatrist–is the same as a 45 minute session with a social worker.” (I’m picturing them as punch holes on a coffee card–a venti mocha with extra whip gets the same amount of punches as a tall Tanzania blend even thought the price difference between the two is $2.50)
CF: “That’s correct. Both are considered visits. So you used all the 85 percent visits on your counseling.”
Me: “That’s very interesting. All of this. Because it’s the first time I’ve heard about this equation or, what I would call, contractual loophole. I guess I’ll have to retain an attorney and have her settle this matter, because someone is feeding me a big lie and I think it’s you.”
CF: “You do that, Ma’am.”
When I hung up the phone I burst into tears. Over-sized alligator tears, pig snorts to accompany them.
I couldn’t stop. I wanted to, but I couldn’t. So when David came into my bedroom, he caught me crying as I held the phone in one hand and all of the damn explanations of benefits and bills in the other.
“Why are you crying, Mom?” he asked.
I took him on my lap and tried to explain preschool “Sicko”: “You know when somebody promises he’ll do something for you–like let you borrow his Ravens football helmet–and then he changes his mind at the last minute and goes back on his word? That’s what happened to Mom. But I’ll be okay.”

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