You hear it all the time. So-and-so needs an operation and the insurance company decides not to pay for it. The insurance companies are painted pretty black and with a pretty broad brush. However, our experience with our insurance company has been just incredibly good. When Kepler was in the NICU, his hospital bill was $42,000 and insurance covered all but $200. We have excellent customer service, excellent benefits, and clear paperwork.

The only tricky part is when I decide to utilize a provider who is the dreaded “OUT-OF-NETWORK.” Out-of-network claims always seem to take two or three tries, and I do get different answers from different customer service reps about these claims. But, still, overall our insurance company does a great job.

I’ve mentioned my fine therapy group I attend. The cost is $40 per session. Our insurance covers this service 70-30. That is, they pay 70% and I pay 30%. I went into this group planning to pay $12 per session, once I received my reimbursement.

Oh, how easy it is to adopt a sense of entitlement. For some reason, in 2007, the sessions’ “allowed amount” was $40. Once January rolled around, apparently, the “allowed amount” became $25.89. So, finally in June, I am having time to get this figured out. My very helpful CSR told me today that it looks like the pricing changed at the first of the year. She assured me that the coverage is still 70-30, but the company decided to pay 70-30 of a lower amount. To confound matters and compound the problem, my provider used a different (wrong) code for my February charges, so they still went through as $40 amount allowed.

I started getting a little frustrated on the phone (28 minutes) because I can’t get an answer as to WHY the allowed amount would change. If this procedure is worth $40 in 2007 surely it’s not worth less in 2008. The only explanation she gave me is that the company is reining in out-of-network providers to more closely match in-network providers. This seems arbitrary to me, although I can understand that there have to be some limits. After all, you could go to an out-of-network provider who decided to charge 2x or 3x the going rate in your area, and then that probably would be a problem for the provider.

So, the bottom line is this. I am so thankful for our health insurance. And having 70% of $26 paid is better than having 0% paid, which is the case for a lot of people. So, I will adjust. I would just like to understand how such changes come about. Did the fact that I had several claims of this sort in 2007 put up a red flag? Are there people who work for insurance companies who do nothing but figure out how to pay less benefits? As it is, our health insurance costs already went up at the beginning of the year, so it’s a double whammy to also have the benefits reduced.

I will adjust. But I don’t like the fact that I have absolutely no input nor recourse about my health insurance costs and benefits and coverage. Ultimately, the fact is, we have better health insurance than the majority of people, so I need to remember that. But it was just a shock to find out that things had changed so drastically. My payment will go from $12 to $22, which will add up over a number of weeks ($500 for the year).

A supervisor is supposed to call me early next week to give me more information about how this process happens, so I hope to take some time to think about some clear, concise questions to ask if and when the super calls.

Upon further consideration, I have NOTHING to complain about.

Go Anthem!!