Legislators, please help my profession by legislating changes so that we can take care of our families by earning what we should be earning. The changes I suggested would also ensure that potential therapists of tomorrow are not persuaded to go into other non-diploma careers that pay more. Please do not allow psychotherapists to be sold down the drain as your children and your children’s children can really benefit by what we have to offer.

  On Saturday, May 4, 2002 at approximately 11:45 p.m., I took my son and his friend to the emergency room at Citizens Hospital for injuries that happened due to an assault.  I immediately went to sign both boys in at the front desk and asked what the procedure would be to have them seen and administered.  I was told that they take people in on a first come first serve bases, which I understood.  It was visible to all that these boys were badly injured and had visible serious head wounds and were both bleeding profusely.  We stayed as calm as possible and held on to their injuries with the towels that we brought from home.

Suzanne XXXX

You know who I mean. I can tell you that I was raised in this system and when I married, quickly got out of there as soon as I could. They were responsible for my dad’s death. This was 1975 when he had his heart surgery. They put in a faulty valve and he died that very night after the surgery. The faulty valve was discovered only 2 days later and hit the news that these certain valves were faulty. But that couldn’t bring him back. We had to endure a lawsuit (my mom and I) & hired a lawyer/doctor to represent us. Many months later, they settled “out of court” for a paltry sum, we never could get to the courts to hear the case. My mom has since passed away. I have more horror stores as to “the hands of stupidity”. During the time I was in my early 20’s I had what later was diagnosed by a real doctor at a wonderful teaching hospital as a hormone imbalance. But before this diagnosis, the hands of stupidity tried giving me a d & c, several shots of depo provera (which was later banned by the FDA), and this shot gave me phlebitis in my legs! I kept going to the emergency room where the hands of stupidity would keep giving me more shots of depo provera, and they were wondering what was wrong with me. I also had a bad bladder infection, which they could never diagnose. At the wonderful teaching hospital this was discovered as well and they said that the white count was so high they couldn’t even count it!! I had to endure years of going to urologists for treatment and had kidney x rays to see if I had any damage. It was awful. To this day, I am messed up a bit from this bladder infection. My own dad had to pay out of his pocket for me to go to this teaching hospital and get diagnosed. I remember him laying me down on the floor of the emergency room (he carried me in) and telling them to fix me. They did and they were wonderful. But the hands of stupidity are still there…they are not real doctors!!

10. Your annual breast exam is conducted at Hooters.

9. Directions to your doctor’s office include, “Take a left when you enter the trailer park.”

8. The tongue depressors taste faintly of Fudgesicles.

7. The only proctologist in the plan is “Gus” from Roto-Rooter.

6. The only item listed under Preventive Care coverage is “An apple a day.”

5. Your “primary care physician” is wearing the pants you gave to Goodwill last month.

4. “The patient is responsible for 200% of out-of-network charges” is not a typo.

3.The only expense covered 100% is embalming.

2. Your Prozac comes in different colors with little “M”s on them.

1. Your ask for Viagra; you get a Popsicle stick and duct tape.

From “New Mexico Highways” magazine.

All’s not well: While vacationing in Angel Fire, Connie Maxwell of Johnson, Iowa, filed a medical claim with Wellmark, Blue Cross Blue Shield of Iowa. The company responded with an explanation of procedures to follow when out of the country.

Maxwell then called the processing service and explained that New Mexico was in the United States, but to no avail.

“Is the claim filled out in English?” the customer service rep asked.

Maxwell asked the rep if she realized New Mexico was located between Colorado and Arizona.

“Yes,” she snapped, and asked again if the form was filled out in English. Maxwell said that it was, then was transferred to another rep.

But explaining the situaiton to the new rep was all for naught.

“She said to fax it to her, she neede to check it to see if it would be an international claim or not,” Maxwell says. “Unbelievable.”

November 20, 2000

Councilmember Ruth Galanter Los Angeles City Council Westside District Office 7166 W. Manchester Avenue Westchester, CA 90045

Dear Ms. Galanter,

As a member of your constituency in council district 6, I am requesting your help in holding Blue Cross of California accountable for misrepresentation of coverage. It has come to my attention through denied emergency room insurance claims that several Southland emergency rooms are no longer negotiating physician contracts with Blue Cross of California. Blue Cross of California is therefore denying ER claims, deeming them “out of network.” However, Blue Cross continues to sell corporate and individual policies stating emergency room coverage after a one hundred dollar deductible is paid. This fraudulent activity is not only a gross misrepresentation of coverage, it is a blatant lie.

Dr. Slay, ER Physician Medical Director at Daniel Freeman Marina Hospital informed me that due to Blue Cross of California paying “abysmal reimbursement” to doctors, hospitals are refusing to renegotiate contracts with Blue Cross of California. However, Blue Cross continues to sell policies with emergency room coverage. Blue Cross also continues to collect premiums on existing policies, charging for emergency room coverage which they then refuse to provide. This is clearly insurance fraud. In speaking repeatedly with Blue Cross over the past year and a half, I have been edified by Blue Cross agents with the knowledge that the Blue Cross policy holders, not they, will bear the cost of these contract disputes by being forced to pay out of pocket for ER care. Dr. Slay explained that he receives daily calls from shocked patients who are being billed, in addition to the one hundred dollar co-pay, for ER visits. These patients were falsely led by Blue Cross into believing that they had emergency room coverage as is stated in their policies, unaware of contract disputes beyond their control.  

I discussed with Dr. Slay the fact that a Blue Cross agent reprehensibly suggested that the next time my three month old baby is in need of emergency medical care, we should drive an hour and a half to “contracted” Torrance Memorial, and only then will they cover an ER bill, since Torrance Memorial is listed as having contracted physicians. Unfortunately, Dr. Slay informed me that this is incorrect as Torrance Memorial’s physicians are also dropping Blue Cross by refusing to renegotiate a contract. I was then astounded to find that each hospital I called yesterday is dropping Blue Cross by refusing to negotiate contracts including St. John’s Medical Center and Cedars Sinai citing unacceptable reimbursement. We, the policy holders, are all left with no ER physician coverage.

Blue Cross continues to sell and collect premiums with impunity on policies stating emergency room coverage with a one hundred dollar co-pay outlined in their benefits package without disclosing the fact that they are unable to negotiate physician contracts and provide this outlined coverage. I have paid several hundreds of dollars over the co-pay in recent months alone. Dr. Slay and I were lamenting over how tragic it would be if one of your constituents were to be in a major accident and require emergency care. They could lose their home due to lack of insurance coverage, which they falsely believed they had in their erroneous Blue Cross policy.

It is incorrigible that Blue Cross pays, as Dr. Slay pointed out, “less than Medicare” to doctors yet they are not charging the same “abysmal” premiums to their customers. I have a masters degree in clinical psychology and currently work as a client advocate. I will now advocate to ensure that consumers know that their private Blue Cross health policy is considered “worse than Medicare” by doctors and hospitals. I believe that the only way to hold Blue Cross accountable is through generating heat in the media through a public outcry. I have collected several articles from the Los Angeles Times about the Blue Cross negligent denial of coverage and their dishonest, incompetent service. It is obvious that we need much more media attention. I plan to rally those who have been denied coverage and paper Los Angeles clinics, doctor’s offices and emergency rooms with flyers alerting Blue Cross policy holders of their unconscionable service and lack of coverage. After a year and a half of egregious service from Blue Cross it has become obvious that this matter can only be settled through a class action law suit. (After an internal appeals process that took 65 hours of my time, Blue Cross paid an additional $70 toward a claim, refusing to cover the entire claim stating that being brought to an emergency room in an ambulance unable to breathe is obviously not a true emergency. And furthermore, if I wanted to use my insurance the ambulance should have driven to “contracted” doctors.) If every single one of their policy holders, both individual and group, switches to another insurance company and seeks legal action for denied coverage that was guaranteed and paid for, I am certain that needed changes will go into effect. 

My husband met with his Human Resources Department in the hopes of persuading them to switch from Blue Cross to another health care provider. Due to multiple complaints, we were guaranteed that they would drop their Blue Cross large group corporate policy and switch to another health care insurance provider by February, 2001. We informed the company’s insurance broker of Blue Cross having costly yet “Medicare equivalent” coverage. Insurance brokers should offer less expensive yet consumer friendly policies to their consumers. Free of Blue Cross in February, I will continue to advocate for patient rights. Armed with the knowledge provided to me by the doctors and hospitals I am speaking to, I am going to my list of human resource department contacts to enlist corporations in Los Angeles and Orange County to switch from Blue Cross to another health care provider who will provide emergency medical care coverage to their employees.  

I am requesting a full investigation of the Blue Cross by the California State Insurance Commission Fraud Division. I am in the process of writing letters to every major newspaper and television station in Los Angeles and Orange County. I am contacting Senator Dianne Feinstein and Senator Barbara Boxer to alert them of what Blue Cross of California is doing to their constituents. In this most turbulent time for our country when the question of quality healthcare is on everyone’s mind, we need government to step in and ensure that doctors are adequately paid and policy holders are adequately covered. Policy holders have the support of the physicians and hospitals. It has been my experience that together we can effect change. I am requesting your assistance in this most grievous and urgent matter. Thank you for your continued work and concern for those of us in district 6.

Sincerely, 

Colleen Kelly

I decided to get back at Kaiser Permanente. They have take up the practice of not treating ailments unless the patient (me) has been in twice.

Big mistake on their part. I have allergies. Everybody KNOWS I have allergies including the Kaiser practitioners. Well, I went in for a series of ‘dry red sploches’ up ONE arm. The doctor asked (again) if I had allergies. Then she asked if I had any animals. I have a dog. She informed me to ‘wash the dog in dandriff shampoo’ because of the dander. I didn’t think this was appropriate because even if I were allergic to the dog doing that was not going to clear up the sploches.

But being the obidient patient (I’m not a child either) I did as she said and guess what? The sploches are still there and getting worse. So if I want to get something done about them I have to go back to her, at her recommendation. NOT!

I can keep them under control and stop them from being really gross but they won’t go away. So, I wear short or sleeveless shirts so other people see them. If they ask or pay to much attention to them I tell them I went to Kaiser and all I got was this lousy rash!

Since they don’t bother me too much I plan on taking advantage of it until I HAVE to have it taken care of.

Oh, at this same appointment AFTER she told me to use a dandriff shampoo, I told her I was having problems with my nose. She looks in my nose and asks (again) do you have allergies. DUH! Didn’t we just go over that?

My problem is not life threatening so I can use it against Kaiser. I do NOT however recommend it for all ailments. In other words, don’t do this if it causes harm to yourself or others. But word of mouth is the best advertisement

Hi again, Part 3 of the Blue Cross soap opera.

I am now involved in a lawsuit with yet another Blue Cross. This one has denied payments for prescription drugs, doctor services, diagnostic tests, and for “durable medical equipment” DME, in this case a scooter to allow me to get around in spite of my severe Chronic Fatigue Syndrome (CFS).

When I first became disabled with CFS, I continued my insurance coverage with Guardian, under COBRA. They paid for all drugs prescribed, including one that was not approved by the FDA for marketing and had to be formulated by the pharmacist. (Components used to make it were FDA-approved as required by federal law.)

When the COBRA period ran out, I wound up joining another Blue Cross plan, a PPO. Not my first choice, but I was assured at the time that BC was a great plan in this area. (NOT!)

BC starting refusing to pay for prescription drugs right away. For one, they used a series of excuses, all lies, including that it was not a prescription drug, that it was a food additive, a food supplement, a vitamin, not a vitamin (!), and not in their formulary. For the one that had to be pharmacy formulated, they simply claimed that it was available OTC, which it was not.

As usual, when first contacted about this, they said “oh, you can’t just look at the benefits booklet. You need to look at the contract.” Unfortunately for them, we HAD the contract. After 4 times through their appeal land grievance system, nothing had changed. They still had not stated any reason for their denial of these drugs. Finally, after suit was filed, they declared that they had a “long-standing” medical policy about that drug and its coverage. They eventually showed it to us, under a strict confidentiality order. It was dated 1999 - 4 years AFTER their first denials of this drug. Longstanding indeed.

They also refused to pay for various diagnostic tests ordered by my various doctors. In explaining this when I appealed, they stated that “diagnostic services are not covered under your Plan.” There are 6 pages in the contract about coverage for diagnostic tests.

They also refused to pay for trigger point injections, stating initially that “Your plan does not provide for this SURGICAL service.” My doctor’s office called about this, and was instructed to resubmit it using a different code number. Vast improvement (NOT!): now it was “Your plan does not provide for this ANAESTHESIA service.” On appeal, they stated flatly that “therapeutic injections are not covered under your Plan.” The contract states, in black and white, that therapeutic injections are covered; no exceptions, exclusions, or need for pre-approval. BC repeated this lie a total of 3 times in writing, including once by an outside attorney after I filed a bad faith lawsuit.

When I started getting worse, and less able to walk, my doctor recommended an electric scooter for mobility. BC sent me to a “Independent Medical Examination” (IME). Their IME dr. did the tests prescribed by BC, and declared that “there is no reason why [I] should not receive” a scooter. The scooter company put the paperwork through, only to have it denied on the grounds that “the tests were all normal.” Looking at the tests in hindsight and with the benefit of seeing another of their secret medical policies, I can see what they did: they prescribed tests that if positive would bar me from getting a scooter, and if all were negative they could (and did) say “the tests are all negative” so he doesn’t need one. Heads I win, tails you lose.

When they tried to defend their actions in appeal, and later in the lawsuit, they quoted from this secret medical guideline. At least, they put quote marks around the stuff they were saying - but they left out a couple of important details that would have shifted me into the eligible category. They also, in another area, flat contradicted their own secret medical policy.

As for the lawsuit, they have defended vigorously. Four times (6 if you count reconsideration and certification for appeal requests) they have tried to have it thrown out because they claim they are exempt from state law. (The mere fact that their interpretation of the particular law they are claiming exemption under leads to logical contradictions is irrelevant; this isn’t logic after all, its a legal action.) They also started out saying “this is just a simple contract action…”, then later claimed that there is no contract action. They have also claimed that the magical incantation “as determined by the Plan” allows them absolute freedom in determining coverage. (The mere fact that many courts including federal Circuit courts, the US Supreme Court and many state Superior and Supreme courts have already ruled that this is not the case, somehow never quite makes it to their legal briefs, in spite of the legal ethics canon require “absolute candor (full disclosure) to the tribunal.”)

They have already succeeded in delaying trial twice. They have violated court orders - nothing new for BC, as I have seen a case where they agreed to settle if the suit was dropped, then refused to pay the settlement! They have also sought court orders to go through my attorney’s personal medical records, starting 4 years before I ever met him. (They later claimed that was a “mistake” - but somehow it never got corrected in court.)

Their most recent legal maneuver is to try to exclude all of our evidence. They are trying to get our expert witnesses excluded; get the court to order that we cannot reveal the secret medical policy to the jury (the original court confidentiality order explicitly says that it can be), seeks to exclude public documents available from the CDC and NIH, and even tries to throw out some of the letters between me and BC. They are also claiming that “cost containment” is not a policy they use - even though their own annual reports state that cost containment is the number one priority.

BTW, this BC had, in 1998, a record $220 million profit (oops, they are NON-profit, so they can’t have a profit - call it a “surplus” instead.) Immediately following that, they 1) requested a 30% rate increase, and 2) demanded 15%reimbursement reductions from all providers. Not surprisingly in this state, they got a rate increase - 10% - and some reductions, about 5%. Also not surprisingly, in 1999 they had another record profit (excuse me, _surplus_) of $250 million. They now have in excess of half a billion dollars sitting in various investments, not earmarked for any expenses. Gee, I wonder why medical costs are going up?

Hi again, Part 2 of the Blue Cross soap opera.

When I was working for a small company, they purchased individual BC policies for us. These policies all had a $2000 pre-existing condition limitation for the first year.

There were 3 of us who exceeded the $2000. One broke her foot 6 months after starting work. This was denied as a “pre-existing condition.” No amount of additional information or appeals or grievances would change that. Eventually, what did change it (15 months later) was that she had a secondary insurer through her husband’s employer, and they paid it. The secondary insurer then sent to Blue Cross a letter saying essentially “we have as many lawyers as you do, and will not only win this case but get punitive damages from it.”

The second instance was me - I tore a cartilage in my knee. The bill for surgery for this was split into 2 parts: one from the surgeon, another from the clinic where the surgery took place. The clinic (with attorney on retainer) was paid immediately. The surgeon was not because BC labeled the problem as “pre-existing condition: rheumatoid arthritis.” My doctor offered to send them the film of the surgery, showing quite clearly a large piece of cartilage floating around in the joint. BC didn’t want to see it, and would not change their denial. They continued to refuse to change the denial, until a letter from my surgeon’s attorney went out, threatening to not only sue, and for punitive damages, but to introduce a resolution into his chapter of the AMA calling on members to stop participating in Blue Cross plans. That got their attention - and they finally paid the bill - over a year after it was first submitted.

The third is the most ridiculous. A coworker’s newborn child was having breathing problems, and was taken by ambulance to the ER, and subsequently admitted to the neonatal ICU. The bills topped $30,000. BC refused to pay, on the grounds that “your contract does not provide for WELL-CHILD CARE.” As usual, appeals and grievances were futile. The hospital, being afraid of what BC could do to them in the way of delaying or denying payments, did not press BC for payment. Instead they went after my coworker. Unfortunately he didn’t have a strong player on his side, or an attorney familiar with health care and BC’s charades. He did, however, have a job offer elsewhere, and to my knowledge the bill remains unpaid to this time. (IMO serves the hospital right.)

Hi.

I actually have a whole series of horror stories, all brought about by one Blue Cross or another.

My first run-in with managed care was when I went to the HMO emergency room - a hour away by bus - for severe pain in my back right where the kidneys are. After a 4-hour wait they managed to take a urine sample, and tested it with a dipstick that can detect the 6 or 8 most common infectious bacteria. Since that came up normal, they sent me away with instructions to make an appointment with my primary care physician (PCP).

I did that, figuring I could bear the pain for that long. Two weeks later I went to see the PCP, only to be told that she was not on this service today and I should reschedule. Two weeks after that, I actually did manage to see her. She ordered some blood tests and a urinalysis, and referred me to a urologist.

Fours more weeks went by before I could see the urologist. When I went there, he ordered another urinalysis - the one ordered by my PCP had been THROWN OUT because a PCP is not authorized to order a urinalysis!

Two more weeks of pain, and I went back, only to find that there were no clear results and I should have yet another test.

It took 6 more weeks to get that test scheduled. When I showed up, I was told that the machine that develops the X-ray films was not working, and I would have to reschedule. Four more weeks.

The total elapsed time is now about 6 months. If this had been an unusual kidney infection I would have long since been dead. Apparently the HMO wished I was.

About that time I went to an outside doctor, who ordered tests including X-rays and a complete blood and urine workup. In his hands, they took 2 days to get results.

I submitted these bills to my HMO. they of course said that they wouldn’t pay - but eventually did. Maybe the fact that I could cite several medical residents who, upon hearing the story, all said “malpractice.”

By the way, the pain actually turned out to be unrelated to my kidneys - it was the first of many “trigger points” that I have had.

More next installment.