Get with the plan? I thought I did

My two recent exchanges with my health plan were bizarre at best – and irritating at worst.
Let me first explain that I have good health insurance coverage. I won’t name the plan, but it’s one of the biggies, and while the policy keeps going up in price, it’s not going to break the family bank.

Let me also note that I am a journalist who has reported on the health insurance industry for 18 years. I have long considered myself an educated health care consumer, and I believed that nothing would surprise me. (Wrong!)

The first call I made on that October morning concerned a letter I had received from my insurer.

The initial paragraph informed me the insurance company had been attempting to reach me by phone, but had been unsuccessful. Then the insurer wrote that it wanted to discuss its diabetes program with me, and that it would help me with my diabetes treatment. “Living with a chronic disease can be challenging,” the letter said.

There was only one problem: I don’t have diabetes.

My first thought had been a stab of fear. Did my health plan know something I didn’t know? But I comforted myself with the fact that I had just completed a physical, and my doctor had pronounced me in good shape, with no major chronic diseases.

Medication alert?

So I called the designated diabetes number and told the health plan person that the letter was a mistake. Taken aback, he informed me that I must have taken a medication that indicated diabetes.

I wondered about that, because I had been taking the same prescriptions for quite a while. I also wondered about the accuracy of the insurer’s records.

I’m very much aware that diabetes is a serious concern for Americans, and managing it can save costs as well as preserve a person’s health. I applaud the effort to educate and help patients manage the disease. That’s why I didn’t get too upset with the poor guy on the other end of the call. He ultimately apologized, and I moved on.

The second communication propelled me immediately into the voice-mail labyrinth constructed by the health plan for questions about benefits.

I had just gotten a flu shot at a retail pharmacy, and I wondered why I was charged a $25 co-pay. After all, wasn’t this the type of preventive care that the new health care reform law required insurers to cover at 100 percent? The co-pay wasn’t going to sink me into poverty, but 25 bucks is 25 bucks, especially if I can keep it in my pocket.

So after shouting “REPRESENTATIVE” into the phone four or five times, I finally got a live human being on the line. This health plan rep said the reason that I was charged a co-pay was that the pharmacy wasn’t ”in network.”

“Wait a minute,” I said. “It’s where I fill prescriptions, at in-network rates.”

“It’s not in-network,” the person replied, in a quieter tone.

Better communication needed

So I explained that here I was, doing my wellness thing, at a convenient place and time, and saving the insurance company some future costs by preventing illness. Why was this unnecessary barrier put in my way?

But the insurer rep simply went back to the script, or what some of us would call the fine print. Apparently the free flu shots applied to medical in-network benefits, and the retail pharmacy wasn’t an in-network medical provider. So if I had gone to a doctor’s office, in network, the shot would have been paid for, but a shot at the pharmacy was not.

I understood the distinction once he explained it. But practically speaking, it still didn’t make sense, because a shot at the doctor’s office could have cost the insurer more than the retail outlet’s $25 charge.

I told the insurer rep that a little better communication would help consumers get the shot for free. The rep listened politely, letting me have my say.

Now, as I reflect on the two encounters, I must admit that no harm was done, except for the $25 damage to my wallet. Still, the two episodes show that even a wise and alert consumer (which is what I consider myself) can be tripped up by insurance language and rules.

Maybe I should have called the insurer first to ask about retail flu shots. Maybe next time I will.

The takeaway message is that it’s best to stay on your toes when dealing with your health plan.

I’m $25 wiser. And thankful that I don’t have diabetes.