Your Insurance: No Longer Accepted Here

It’s Wednesday, 6 days after The News.

Your Insurance: No Longer Accepted Here

I have a grandfathered PPO plan which I originally got in 2009 – pre-ACA. Being in the tech industry with its associated generous income I figured I could handle medical expenses up to the deductible (currently $5,900 – for perspective this is rather lower than the annual premiums on the plan, lower than the real estate taxes I pay on my townhouse, and much, much lower than the annual rent I’d pay on a one bedroom apartment!) . But, not being filthy rich, I wanted insurance to kick in for “catastrophic” medical situations, such as the one I’m in now. I haven’t changed it since ever since the ACA took effect PPO plans have been rather difficult to come by in the individual market. The ACA hasn’t been kind to professionals like myself who had individual plans. And I always wanted the flexibility to go out of network if the need arose.

I had called Anthem Blue Cross on Monday to talk to a service representative about my plan, confirm various limits, and ask for their advice on how to ensure I didn’t get surprise claim denials.

Until today everything was going smoothly.

Then came a bevy of calls from the office of the gastroenterologist performing the endoscopic ultrasound tomorrow. The first was to move the procedure up an hour. This caused a flurry of activity since JT, who was going to pick me up couldn’t, but another friend was able to. Problem solved.

Then came a few more calls. Sequoia Hospital, where the EUS was to be performed was no longer in the Blue Cross network. What?! Like this is happening just now?! The person calling asked if I wanted to keep the appointment – a lot of people were cancelling for insurance reasons. Ok, well I have a PPO plan, so I can go out of network. What’s the it going to cost? She didn’t know since she’s with PAMF and not Sequoia Hospital. It might be $4-$5k, but really I’d need to call Sequoia Hospital’s billing department and they could give me the price. Ok, well, I can afford $4-5k so I decided to keep the appointment. It’s important since I have consultations with a surgeon and a medical oncologist coming up. All this was happening while I was having lunch in downtown Palo Alto after picking up JT from her own medical appointment. Fortunately she has a bit more experience with dealing with medical bills and suggested I ask the hospital for the cash price, which is the price that would figure into my out-of-network deductible and co-pay.

When I got home I called Sequoia Hospital’s billing department and ended up listening to that ever-irritating elevator music many companies use while you’re on hold. I’m sure the music is specially selected to drive callers to hang up. While on hold I got a call from PAMF. I wasn’t sure who at PAMF was calling since they just show up as “Palo Alto Medical Foundation” on my phone and as you might imagine I’ve been getting tons of calls from many departments. But anything was better than the hold music. It turned out to be the office of the gastroenterologist, and they had been able to get a price. $15,815.46, plus there may be additional facility and anesthesia fees. Ok that’s quite a bit higher than I was thinking. It’d take a nice bite out of the cash I had on hand, and was definitely starting to hit a pain threshold. My PPO deductible is in the $12k range, after which Anthem will cover 80%. So I’d still be on the hook for the majority of that $16k+. I told the gastroenterologist’s assistant that the EUS is critical so if it has to be at Sequoia, so be it – I’ll keep it. But was there any way the EUS could be moved to a PAMF site? And oh yes, the results need to be in the hands of the surgeon before the Monday morning consultation. She said she’d send an urgent message to the gastroenterologist and see if there was a way to work something out.

An hour or two later I got a call back: they were able to move the EUS to the PAMF San Carlos surgery center and create a slot on Friday morning! Great news! And the friend who was going to pick me up on Thursday could manage the revised time as well.

Once again I feel someone up there is watching over me, though it seems I spent a good chunk of the afternoon on the phone rescheduling, trying to get pricing, or arranging for pickup. I also continue to be grateful for the people at PAMF, who continue to go out of their way to speed my diagnosis along.

The worst of it, though, was missing a rare gastronomic opportunity. See, until the reschedule I was prepping for a Thursday EUS. Which meant fasting after 12:00 PM. If you recall I was in downtown Palo Alto…and we happened to stop at one of my all-time favorite chocolatiers, Alegio. They had a tough time during the pandemic and were unable to get inventory from their manufacturing facility in Sao Tome. They even closed their other location in Berkeley. I was pleasantly surprised to find them open, with the owner, Panos (“DO NOT CHEW THE CHOCOLATE”) Panagos, manning the store. They had just gotten their first shipment since the pandemic from Sao Tome. Imagine how disappointed I was when Panos offered us to sample some of the new arrivals and I had to turn it down! There are important things in life. And chocolate is one of them. I did get a box of 100% chocolate-covered ginger balls (pricey but definitely worth the rare indulgence!) and JT got the 70% chocolate “ubric” brick with muscat-soaked raisins (it is goes very well with a glass of muscat). For those of you coffee lovers out there the 70% chocolate with liberica coffee beans is another of Alegio’s delectible offerings.

If you’re wondering what’s up with Sequoia Hospital and Blue Cross, there have apparently been a number of disputes between Anthem Blue Cross and local hospitals. In early July El Camino Hospital in Mountain View stopped accepting Blue Cross. Blue Cross started referring patients to other hospitals, including Sequoia Hospital. Over the years Stanford Hospital and Palo Alto Medical Foundation also ended up in contract disputes and for a time did not accept Blue Cross.

The following article reports on the El Camino Hospital dispute:

Hospitals clash with Anthem Blue Cross over health care prices, leaving patients in a lurch

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