Red Tape

Friday, the kids and I spent literally the *entire* day dealing with the pediatric gastroenterologist's office and with our health insurance company. Now, don't get me wrong, I am very happy with this doctor - he is one of the best around - and I'm also very happy with our insurance (I thank God that we have such great coverage for such a low premium through Steve's work) but sometimes, I just wish something in life could be simple!

Basically, the GI ordered some further testing to try to finally get to the bottom of the problems Teresa has been experiencing (I'll get to that in a later post in case anyone else has any ideas) and I wanted to have some of them (the abdominal ultrasound and the blood draw) done there at CHOP. The receptionist was telling me that with my insurance, I couldn't - I'd have to have all those tests done at the sites where we're capitated for radiology and lab work. That made no sense, since Teresa just had an upper GI series last month at CHOP, and there was no problem. And, I'm sorry, but I don't want her going to a non-pediatric facility - I really think there's a definite difference, when you're talking about a radiology staff that deals with kids and kids' anatomy day-in and day-out versus one that deals with adults 99% of the time. And when it comes to a stick for labs - I'm sure that a phlebotomist who is used to kids can make it a better experience (uh - relatively!) than it would be otherwise.

So Teresa was seen by the doctor (and by the way, why is it that nowadays, at all the decent medical facilities around here, patients get only a 15-minute grace period to be late and not have to reschedule their appointments, including a patient who happened to have been sitting in horrendous traffic for nearly two hours, with 3 small children, alone, and then had to circle the block for 25 minutes looking for a parking spot that could accommodate her minivan since the hospital parking lot has a "SORRY, FULL EXCEPT FOR MONTHLY" sign up by like 7:30 am; but yet the doctor can keep said person waiting, with said 3 small children, for an hour and a half, and not even say, "Sorry to keep you waiting, ma'am," anymore?) But he was very thorough, had a halfway decent bedside manner, convinced me really knew his stuff, and made a long-ish list of things to try to start ruling out.

So I took the kids to go get some lunch while I called the insurance company to sort out the regulations. They told me I'd need a pre-cert to take Teresa to CHOP for the ultrasound. So I get transferred to the pre-cert department and launch into my story of how I'm not taking her to an adult facility because blah, blah - and then the woman tells me that capitation rules only apply to kids 5 and over - from birth through age 4 they can go anywhere I want, in-network and with a referral, of course. So we finish lunch, walk back to the office, and head back up to GI to have her labs drawn and schedule her u/s.

At which point the receptionist tells me that my insurance company must be wrong, because she's never heard of any capitation rules depending on age. And she refuses to send us to the lab, saying that she's protecting me, since it will cost me like $900 if the insurance company refuses to pay. So I get BACK on the phone with the insurance company, proceed to speak to *THREE* different people, and get *THREE* different interpretations of the cap rules. AAARRRRRGGGGGHHHHH!!!!!! By now it's like 3 pm, and we've been there since around 10 am. I wait - and wait - and wait - on hold. Insurance guy is getting his supervisor on the phone. GI receptionist is getting Patient Services Coordinator paged to come up and deal with me. Other patients' parents are looking at me like, "OH, there's one of those problem moms arguing with the staff. What's wrong with those people?"

In the end, insurance supervisor tells me she is not sure of the correct information (Really?? Has nobody EVER asked this question??) and will need to research it and call me back. And it doesn't matter anyway, since the issue has now become moot - it's 4 pm and the lab techs are going home, not waiting for the crazy mom who has been standing in the waiting room on her cell phone for an hour, insisting that they draw her kids' blood - and, oh, did I mention, losing one of her other kids in the process?

Oh yeah, that was great - Andrew, I seem to keep forgetting, is bipedal these days. He's been walking for like, all of 4 minutes, but he walks fast, and without fear. One minute he is sitting on the floor of the waiting room playing with his sisters, and the next, he apparently decided to walk off down the hallway and wander into an exam room, where he was discovered, fortunately, only a millisecond after I looked behind me at the toys he'd been playing with the last time I checked and yelled, "OHMIGOD - where is...." Before I had even finished my sentence, a nurse appeared around the corner, hunched over walking hand-in-hand with Andrew (who had a huge grin on his face), saying, "Is someone missing a little man in a yellow t-shirt?" It was great - then all the other parentes glared at me thinking, "Aaaaaahhhhhaaaaaa.....so she argues with the staff AND she can't keep track of her own children!"

Fortunately, I finally got my answer. Believe it or not, the receptionist was correct and the first person I spoke to at the insurance company was wrong, about her own policy (go figure!) In our plan, capitation does not apply at all for radiology, but it does apply, to everyone regardless of age, for labs. The confusion apparently stems from the fact that even though we live in, and our doctors practice in, PA, our policy is through a DE employer, so DE laws apply - and in DE they are not allowed to enforce capitation for radiology. Mystery solved.

Of course, by that point I was en route here for some much-needed retail therapy. Sorry, Steve - it's on the way home from the city - and really, don't you think I deserved it?