by Larry Floersch-
My wife and I now find ourselves at that point in life where we are highly susceptible to advertisements for products designed to ease the pain of arthritis, maintain regularity, or keep our teeth (both natural and store-bought) in their assigned places. Included in this category are the pitches for miraculous vaccines offered by the pharmaceutical industry. You too may notice these ads. They usually run during the evening news hour, which is when, because of elevated blood sugar levels from feasting, in our case at early-bird, all-you-can-eat buffets, our will to resist is weakest.
This tale began with such a pitch. My wife once had shingles, the virus of which lurks in your body if you’ve had the chicken pox, waiting to surprise you later in life, much like an LSD flashback. And from what I remembered of her suffering, shingles is a very, very bad “trip.” So when ads about a shingles vaccine began to appear, we took notice. But this tale is not about the vaccine itself. It is about how one gets the vaccine and how it is paid for.
I do not know how things are done in other places, but for us here in Vermont, for reasons that are unclear to me, we could not just go to our doctor and get the vaccination. We had to visit our “primary care provider” (i.e., our doctor), pay the required copay, and get our doctor to arrange for us to get the injections at an establishment that offers shingles vaccinations.
One of those establishments, judging from the signage erected along the approach to the parking lot, is the supermarket, where (and I’m speculating here) someone who is trained in giving injections (a checkout clerk perhaps?) gives you the injection while you sit at a folding table set up next to the bananas in the produce aisle.
Having seen all those ads on the internet that show a picture of a banana and warn you about five foods you should never eat, we felt uncomfortable with the idea of getting an injection in the produce aisle. That may be OK for flu shots, we thought, but we’re talking about shingles here.
We opted instead for our local pharmacy, where a pharmacist delivered the injections amid the relative privacy and comforting words of the greeting card displays. He then produced four bills for the injections: two bills for the injections themselves, which at the time were $208 apiece, and two bills for a $20 copay for each of us, or a total of $456. That left me breathless but protected against shingles. The pharmacist told me that I could be reimbursed for the total amount if I filed a claim with my health insurance provider.
Receipts in hand, I found the website for my health insurance company. The company shall remain nameless here to preserve its dignity, but let’s just say its name is reminiscent of the term for a young swan. On its claims web page I encountered the first hurdle: Was this a medical claim or a pharmacy claim? Each required its own specific form. Being unsure, and being unwilling to take Yogi Berra’s famous advice, “If you come to a fork in the road, take it,” I placed my first call to the company’s helpline. The representative assured me that it was a medical claim. I needed to fill out a medical claim form for each vaccination and send those forms along with copies of all receipts. I happily complied.
The first inkling that the waters ahead were about to become stormy came several weeks later. A notice arrived from the company that the claims were missing “CPT” and “DX” code numbers. I felt totally foolish because of my oversight, for any reasonably intelligent person should know those codes by heart, even if, as I remembered, there were no fields on the forms calling for those codes. I shrugged it off, got the missing codes from our doctor, and sent them in, but, because of my apparently failing mental capacities, secretly began to worry whether a vaccine for senile dementia was in the offing.
Next came a notice that the claims could not be approved because they were pharmacy claims. I called and explained the situation to another company rep, who agreed they were medical claims and said she would push the claims through the system again.
Apparently she was not totally skilled at that process, for the next notice to arrive explained that the total charge for the two vaccinations was now $706.05, that the amount was not covered by my plan, and that I therefore owed the pharmacy $706.05. Again I felt foolish, for it had been my impression that the pharmacy had been totally happy to let me walk out the door after I paid them the $456. It was becoming clear things were not spiraling in my favor.
More calls were made, and each company representative assured me that it would be straightened out. One rep even suggested I had not filed the claims in a manner that would have made it easier for the company’s accounting system. I apologized to him for my ignorance of the company’s accounting system and promised that the next time “Health Care Insurance Accounting for a Company with a Name Similar to That for a Young Swan” was offered online by the folks at The Great Courses I would sign up.
A month later came a breakthrough — a check arrived for one of the claims. Well, actually it was a check for some of the claim. In its haste to get the payment to me, the accounting system had overlooked the receipt I had supplied for the $20 copay at the pharmacy, so it deducted $20 from the claim total. I’m convinced it did this to avoid giving itself a headache. More calls were made, and the next month a check for the missing $20 arrived.
I should have counted myself lucky about getting one claim paid and stopped at that point. I did not. I awaited the check for the second claim. It did not arrive.
I called again. It was getting personal. The accounting system was now avoiding me altogether. I had sent a reduced amount for the claim directly to the pharmacy, the remainder had been applied to my deductible, and I still owed the pharmacy $52.
I phoned again. The company issued a request to have the pharmacy return the money, and I was told the accounting system would graciously allow me to continue to hold the bag, as it were, until the pharmacy complied, because it would find paying the claim very stressful until the money was returned.
Almost eight months after I filed the claim and after 21 calls to the company, a check arrived for the second claim. I cashed the check immediately, just to annoy the accounting system, bought a bottle of Italian Procecco to celebrate, and, while my wife and I sipped it, reflected on how much more difficult it may have been had we gotten those vaccinations next to the bananas.