[OFF TOPIC] Battling the Healthcare Machine

I write these “off topic” posts from time to time as a way of announcing something that isn’t necessarily book-related. Sometimes I write them to vent. Today’s one of those days, folks. If you’ll indulge me for a few minutes, I really need to get something off my chest.

Like everyone else in this country, I have had my own battles with that great big Healthcare machine. Some of you know about the health-related issues I faced last year, and while most of those situations were resolved without incident, I’m still being haunted by one thing in particular.

Last summer I was diagnosed with sleep apnea. It wasn’t a big surprise—most of my family has it, and after a couple of years of deteriorating sleep patterns, I thought it best to go get it checked out. As a result of this diagnosis, I was prescribed a BIPAP machine for sleeping. Basically, it’s a mask I wear when I sleep (it sort of looks like the facehugger from Alien), designed to keep my airways open, and the results are amazing. I haven’t felt this great in years, folks.

Unfortunately, this great invention has also been a source of stress over the last month.

Those of you who deal with health insurance or have utilized it at any length will understand what an out-of-pocket maximum is, but for the uninitiated, your out-of-pocket max is the maximum amount of money you will have to pay out of your own pocket for healthcare. Once you meet your out-of-pocket, everything is covered 100%. Normally it’s difficult and/or unlikely you’ll ever hit this limit, especially if you have a large deductible (although recent healthcare laws have changed what contributes to your out-of-pocket—for the better, I think). However, after all the issues I had last year, I met my out-of-pocket max in late October.

In November, I received my prescription for the BIPAP machine. I picked it up from a local supplier on 11/8/13. A friendly representative walked me through how to use it, explained that it would be billed to my insurance, and that was that. I signed a form acknowledging acceptance of the machine and went about my day.

Fast forward to the beginning of May 2014. I received a bill from the supplier for $89.60. The billing period was for January 2014. I called the supplier to inquire and here’s what they told me: My insurance company (Aetna) opted into a “rent to own” arrangement for the machine, rather than pay for it outright. In this arrangement, the cost of the machine is split over 12 months. The first two months, November and December 2013, were paid 100%.

“Why am I being billed now?”

I asked this question, and was told, “It’s because of your deductible.” To which I responded, “But this was a 2013 claim filed at a point in time when my out-of-pocket had been met.”

This stumped the billing person at the supply company, who suggested I contact my insurance provider. I went one step further and contact my day job’s benefits coordinator to explain the issue. She reached out to Aetna, explained the situation to a representative there, and was informed that it’s a mix-up, that the supplier should be sending those bills to Aetna, not me. In short, I don’t have to pay it.

Naturally I was relieved by this. If I’d known the machine would cost me over $500 for the year, I never would’ve accepted it in the first place. No one mentioned a “rental” agreement when I picked up the machine, and I’m not really in a position to take on another monthly payment. Receiving news from Aetna that it’s not my responsibility was a huge weight off my shoulders.

I followed up with the billing manager of the supply company, directed them to call a “Provider Services” number, and asked that they please get this sorted out so they can get paid. “Sure,” she said. “I’ll do that.”

Whether she did or didn’t isn’t an issue, because at some point in the following two weeks, she was let go from her job. I learned this after receiving a second bill—this time for February—and calling to find out what the heck is going on.

After some confusing and, admittedly, heated conversation, I finally got put through to the guy who gave me the machine in the first place. We’ll call him Drew. Drew’s a nice guy, and pleasant to speak with. Unfortunately, by his own admission, Drew didn’t disclose to me that my insurance provider would be paying via this “rent to own” arrangement. No matter, though, because Drew’s going to get to the bottom of this and help me get it sorted. I recapped the situation, explained what Aetna told us, and asked that he call the number to work it out with them. He said he would—and he did.

“We were wrong.”

Jump ahead one more week (e.g. last week). Drew calls me with some confusing and troublesome news. “The person I spoke with at Aetna said it’s your responsibility to pay monthly due to your deductible.” Which contradicts everything Aetna told us two weeks prior. I told him I’d follow up with my benefits coordinator and be in touch.

So I did. She put a call in to my day job’s account rep at Aetna, who called back on Friday with more irksome news: “I’m afraid we were wrong. The service representative who originally told you it would be covered wasn’t correct. This is the client’s responsibility due to the deductible.”

In Aetna’s eyes, the arrangement has absolved them from their obligation to cover the cost of the machine in 2014 due to it being a new year and also on account of my annual deductible. They don’t see this as a single claim, but as twelve—ten of which fall into a separate year when I’ve no longer satisfied my out-of-pocket maximum.

As of right now, based on their monthly billings, I owe this supply company $448.00 (January through May), and as of June, will owe them a little over $500.

To recap:

  • I got the machine with the understanding that it was covered 100% under my out-of-pocket maximum.
  • I started receiving bills in May, retroactive to January.
  • Aetna said they weren’t my responsibility.
  • Aetna later changed its collective mind.
  • I’m stuck with a machine that, while helpful, is going to cost me almost $700 out of pocket after all is said and done, which I can’t readily afford at the moment.

So where to from here?

At this point, I am prepared to return the machine to the supply company and attempt to negotiate the balance due on the account based on the fact that they did not disclose the arrangement at the time I picked up the machine—a fact which would’ve completely changed my decision—and also based on the fact that they waited five months to begin billing me.

Don’t get me wrong, I’ll miss the machine. Unfortunately, I’m not in a place to take on another monthly payment.

Furthermore, I feel it’s not my place to do so. I’m not about to go on a rant that all insurance companies are evil—they are businesses, after all—but I do feel as though Aetna is trying to weasel out of their obligations.

The claim was filed in 2013 at a point when I had met my out-of-pocket, meaning all claims filed would be covered 100% per my policy. How they choose to pay for it should not change the terms of said policy. Unfortunately, they’ve put me in a position where I either pay/negotiate, or take a hit to my credit rating. I feel as though I just got scammed in a bait-and-switch deal. If this isn’t criminal, it is at the very least highly unethical.

This situation has, at the very least, led me to reconsider enrolling with Aetna again in the future. If I can’t count on them to fulfill their obligations, why continue to pay a monthly premium to them? They’re forcing me to vote with my wallet here.

I think I’ve said all I need to say about this for now, but I’ll leave you with a question: What would you do in this situation? Would you pay the bill? Would you keep fighting? I’m curious to hear your answers, and any advice is greatly appreciated.

Oh, and one more thing: Keep politics out of your responses, please. If anyone posts a political comment bashing one side or another, I will delete it on sight.

Thanks for listening,


2 thoughts on “[OFF TOPIC] Battling the Healthcare Machine

  1. Todd, I’m so sorry. This is super sucky and also unethical.

    In my mind, they’re so clearly in the wrong that I’d suggest you keep fighting. I’d also ask around to see if you have any lawyer friends who could suggest other routes. Or even ask if you can use their name. “I’m talking to my lawyer, SO&SO” really has an effect.

    That said, I know how exhausting this is and how attractive it must be to give the machine back. If it didn’t help your quality of life so much, I’d suggest it. But you need it. Keep fighting. We all know how sleep affects depression, etc.

    I’m in a similar vote. You’re talking to a woman who can’t get her antidepressants filled because of insurance hoops. I’m completely out, and my anxiety is eating me alive. Best of luck to you.

  2. Keep fighting! If you have an attorney friends, ask them if they will write a letter for you without having to hire them. I know one of the best in Harrisburg if you end up needing to retain one.

    This is completely unethical.

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