The Sound of Inevitability

So you are thinking that there are two possible reasons that I might have re-opened this blog for business. The first is that my teeth are finally fixed and I am throwing a virtual celebration. The other is that the process is once again in the crapper and I am reaching out to all of you good people to help. There is a third reason: that the situation is so funny, in the way that all good comedy is rooted in tragedy, so perfectly Kafkaesque, that not writing about it seems like a crime. As Captain John Miller put it (or I guess as the writer of Saving Private Ryan put it): “Things have taken a turn for the surreal.” And then the fourth reason is there is nothing like public venting to provide a false sense of vindication, which a fellow needs every once in a while. So the answer is: a combination of the last three reasons, mostly the second, a handful of the third, and a somewhat apologetic dash of the fourth.

I’m not sure exactly where and how to start. A fair bit has happened in the last 14 months, though most of it maddeningly similar to the original nonsense. For those of you who are new this story, or who in the interlude since the preceding post have forgotten the details, which I am sure is near everybody, this blog is largely about my dealings with Humana Health Insurance following a bicycle accident. I took a nasty spill on the Lasalle Street Bridge in downtown Chicago, and metal grating of the roadway made quite a mess of my mouth. To make a long story short (if you want the long story, start here and work your way up), Humana first refused to cover my extensive dental work, then agreed to cover it, and now over a year later, is refusing to cover it once again. Nearly two years have gone by and I am still missing teeth. Are you surprised? Whether or not I ought to be, I must admit that I am. Perhaps because it took so much work, and the invaluable cooperation of so many of you readers to–coerce is such a strong word–prod(?) Humana into reasonableness such that they would actually abide by the terms of their contract with me, I believed that our victory must hold. I guess I had the same unreasonable certainty in my hard-fought dental coverage that Chuck Noland from Cast Away has in his life raft. Apologies for my second Tom Hanks reference. I endured innumerable phone calls, letters, a grievance process, constructed this blog, enlisted the services of The Fixer at the Sun Times before finally getting Humana to agree that, yes, it makes sense to provide medical coverage to the victim of an accident. But getting back to that short story…I think I will start fresh with a new paragraph.

When last we left, Humana had agreed, in writing, to authorize the work of Dr. Reisberg a restorative dentist at the University of Illinois in Chicago. This is the man who was to (hopefully is to) help me get back my smile. However, Humana’s written approval came with a caveat: a 6 month term, after which I would have to reapply for coverage. I found it kind of funny that Humana should put a term of 6 months on putting my face back together after they had essentially denied service for nearly a year, but Dr. Reisberg did not seem discouraged. Extending service beyond the initial coverage window was usually a simple matter. A letter from the provider, in this case him, would suffice. So we got started. After X rays, impressions, and photos, Dr. Reisberg decided that my remaining teeth would need to be straightened before he could drop any implants into my jaw and fill in the gap in my lower teeth. Unfortunately, this would require another specialist, an orthodontist, to take part. I will spare you the details, but you’d better believe there was more fighting through bureaucracy and unnecessary delay involved in getting Humana to agree to this. But eventually Humana did agree, and I got braces and a temporary crown on my broken canine. By this time the 6 month term of service was drawing to a close. I was under the impression that Dr. Reisberg would be writing a letter to extend coverage. A couple of months go by, and I will be the first to admit that it was a bit naive of me to let them go by, and Dr. Reisberg, who has been waiting for the orthodontics to conclude before he could start work again, asks me to contact Humana to see about getting his authorization renewed. This I did. And after speaking with a myriad of people, who seemed to have no idea what I was talking about–apparently getting coverage via a grievance creates a lot of confusion on their end–they agreed, in writing, to extend coverage for my dental work for another six months. But only for the orthodontist. Now in all of my conversations and letters I had asked specifically that Dr. Reisberg be included in the authorization. The majority of work left to be completed would be done by him. When I spoke again with the person on the “Care Access Team” who was responsible for extending the coverage, she told me not to worry about it. Dr Reisberg and my orthodontist work in the same facility and share the same tax ID number. Any claims submitted by Dr. Reisberg would be honored as well. Wise Dr. Reisberg, who has worked with HMOs before, did not believe this. He demanded that before he resumed work Humana must specifically state that authorization for coverage extended to him.

So now I’m sure you can see where this is heading. Dr. Reisberg provided Humana with a formal care plan and they have balked. Essentially, Humana has said: “What?! You want dental implants?! Well, we didn’t know you wanted implants. We never agreed to cover that. If you want implants you are going to have to go back to your primary provider and get a referral.” The way I see it, approving prosthedontic work and then claiming surprise when implants are ordered is sort of like hiring Mike Ditka to give a motivational speech and then objecting to his use of football analogies. Either extreme naiveté or willful ignorance is at play. This is especially true given that the first prosthedontist I met with also proposed dental implants. For those of you who haven’t been following the story from the beginning, or who have and are now confused (which describes me most of the time) it might not be apparent why this is so funny. At this point I feel that I must recap so that the comedy comes through. I will do so in graphical form with the aid of a flow chart. A caveat: I have never used a computer to make a flow chart.

Chronology of obstacles

So that’s it for now. After nearly two years of wrestling with Humana, I am back to square one. Well, not quite at square one. There is clause in my insurance policy which says that if medical treatment following an accident is not completed within two years, Humana does not have to pay. My wife suggested that this is perhaps why Humana has taken their current tack. The last orthodontist I visited with at UIC said something else that I found interesting. He said that it might have been better if I never had health insurance to begin with. Sadly, the same thing had occurred to me more than once.

For the second time, I am filing a grievance with Humana to insist that they allow Dr. Reisberg to go ahead with his care plan. I will probably also re-enlist the help of The Fixer. Other than that, I am open to suggestions. But whatever I do, it will have to be soon. Unless the majority of the rather expensive restorative dentistry is completed by November 23, 2012, I may never be able to re-coup from Humana. The tooth implant process can take up to 6 months. But more than anything, this ridiculous situation has been going on for far too long and I just want it to be over.

Up until this point in my life, I have been fortunate enough to steer clear of this side of private health care reimbursement. Though I work in medicine, I have remained relatively healthy and have been spared the needless frustrations inherent in fighting for care with big insurers. Certainly my struggle with Humana is representative of difficulties a great many people face. When delaying tactics take precedence over addressing health concerns, we are working with a broken system. Perhaps in some small way this blog can help generate discussion on changing the way that health insurers do business. I guess that’s a fifth reason for starting this blog.

So please: share this blog with your friends on Facebook; post a link on Twitter; follow the blog; leave comments and suggestions. The more people this blog reaches, the more likely Humana is to listen. The clock is ticking. Thanks!


About jkasbury

A guy with busted teeth fed up with his HMO.
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1 Response to The Sound of Inevitability

  1. dr. katrin asbury says:

    I am currently shopping around for private health insurance. I certainly know that I wont be going with Humana.

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