Legacy sales tactics

We’ve spent quite a lot of time researching cars, trying to figure out what we want, and doing some test drives. We decided on a 2014 Subaru Legacy with Eyesight late in the winter, but discovered that they had closed factory orders for the year before we made our decision. Argh.

But the 2015 Subaru Legacy was going to be new and improved! Just like every year’s new models are new and improved, but this one actually made improvements we cared about: less road noise, better fuel economy, a new color we liked better, and an upgraded Eyesight safety system that no longer required a bunch of features we didn’t need. The reviews this spring were all stellar, and the car started showing up on dealer lots a few weeks ago. On Sunday we finally found time to take a test drive, discovered that the car was comfortable and handled just like we wanted it to, and finalized the list of options we wanted and didn’t want.

So we’re doing a factory order which will arrive in the late fall, whatever that means. Shopping wasn’t bad: we had a price from the dealership where we took the test drive, and on Monday over lunch I emailed six local dealerships to ask them for a price. Almost all of them asked some meaningless question first, but three of them followed up with a price on Monday, one gave a price on Tuesday morning, and the dealer in North Reading insisted (wrongly) that we could only order a more expensive version than we wanted. We already knew the invoice price and we knew that the best we could reasonably expect on a factory order was about 2% under invoice plus a doc fee, so when the low bidder came in just under that I went over to sign the paperwork and gave them a deposit. No headaches, and all rather anticlimactic. Hopefully it will be just as easy when we pick up the car in a few months.

The dealer in Wakefield was horrible when we went there last year: unprofessional, incredibly rude to other customers, unhelpful to us, and overall seeming like an over-the-top parody of a nightmare dealership. We didn’t even consider asking them for a price. The dealer in North Hampton was overall helpful, though they tried briefly to see if we’d respond to high pressure sales tactics, tried the mysterious back office crap, were clearly used to a foursquare sheet, and tried raising the quoted price by $350 a day later. But they did quote us a perfectly fair price, and were straight about answering the few questions we had. In the end we went with the dealer in Belmont, who could not have been a bigger contrast to the dealer in Wakefield. Hard to believe they compete in the same market.

So the hard part was deciding on the car and putting up with the dealership showrooms. The actual price negotiation over email was far more civilized than I feared it might be. And in a few months, we’ll have the first new car I’ve ever owned.

Follow-up on October 5:

25 days ago, I called the dealer to ask what the timeframe looked like. I was told that our car had been built, and was on its way from Indiana to New Jersey. Once they knew when it would travel from New Jersey to Massachusetts, I would get a call letting me know that the car would arrive at the dealer in 7-10 days.

9 days ago, I noticed that a car with our specs was listed on the dealer’s web site as being in their inventory (not in transit). I called the dealer to ask about it, and was told that the web site was wrong, that our car was still on its way to New Jersey, and that I would get a call once it was ready to leave New Jersey letting me know that the car would arrive at the dealer in 7-10 days. They said that our car’s VIN was not available, but that it was not the car listed on the dealer’s web site (which had a VIN). Our best guess is that the route from Indiana to New Jersey now involves sherpas, sled dogs, and Sharknado 3 instead of rail cars or trucks.

Yesterday the dealer called (during Yom Kippur) to let me know that our car had arrived. There had been no call 7-10 days in advance, and our car’s VIN now mysteriously matched the VIN of the car listed on the dealer’s web site 9 days ago. Hmm. Had our car arrived over a week ago and they just lost track of it? Was the web site simply posting advance information? Have they been using our car for test drives for the past week or two, since they had no other cars with the new Eyesight system? Something went wrong en route, since we never got the call 7-10 days in advance. We’ll check the mileage when we pick up the car next week, but we’ll never know most of the answers.

Rainbow cookies

Fairway carries at least 3 bakery brands of lactose-free rainbow cookies: Oberlander, Delancey, and Lilly’s.

Oberlander makes some very good Passover cakes, but their Passover rainbow cookies are disappointing and their Passover black and white cookies are some odd crumbly styrofoam-based play food that bears no actual resemblance to a black and white cookie and tastes like anti-chocolate. The regular Oberlander rainbow cookies had a bland flavor and mediocre texture.

I know Lilly’s from Whole Foods. They make excellent rugelach and very nice black and white cookies (with a blue and white version for Chanukah last fall). Their rainbow cookies came in an unsliced and comically tall loaf, whose primary ingredient seemed to be dryness. There was no flavor at all.

The Delancey rainbow cookies are ok. The chocolate and fruit flavor components are a bit lacking, but the texture is very good. Compared to the other two brands, they’re delicious.

The Fairway bakery case in Stamford had two house-made rainbow cookies, one with a regular chocolate enrobing and one with a white chocolate enrobing. Unfortunately, ingredients were not available for either one. The Fairway bakery counter said that they weren’t required to provide ingredients. Well, I’m not required to buy their cookies.

Interfaith dues

Most American synagogues operate on a dues model of ensuring financial support for the congregation, where the dues are a set amount and some flexibility is available for lower incomes. Most American churches operate on a voluntary donation model of ensuring financial support for the congregation, where different people pledge and/or donate different amounts. It should be noted that both models fail to keep many congregations in decent financial shape.

I’ve long thought about and avoided the dues model for religious organizations. Most of our annual donations over the past decade have been voluntary donations to organizations which have no set expectations of us, and where we can often feel like we’re exceeding those non-existent expectations.

But now we’re joining a synagogue, and the dues are significantly higher than we’re comfortable with, so I’ve been wondering about the dues policy. I’ve also been wondering about the synagogue’s various policies towards interfaith families, and the confluence of those two mental meanderings is the difficult fact that we want to support both the synagogue and Lisa’s church. What is the right total for us, and what is the right balance for us?

When we were just two people, we made sure that our donations to my religious organization and Lisa’s religious organization were (approximately) equal. That felt right. As three people, the balance is actually much more difficult. Lisa is Christian, David and I are Jewish, so should we give 2/3 to the synagogue and 1/3 to the church? All three of us go to synagogue events, and only Lisa goes to church events, so should we give 3/4 to the synagogue and 1/4 to the church? Should we keep track of how often we actually interact with each community, and base our split on that? Or should we respect the fact that the two adults in the household are two different religions, that we respect and support each other’s religious practices, and continue to give 1/2 to the synagogue and 1/2 to the church?

The right way to think about the total is even harder for me to wrap my head around. If we are members at the synagogue, then we should financially support the synagogue in the same way as all the other members of the synagogue. But that means the total religious expenses for interfaith families are much higher than the total religious expenses for same-faith families. When people owe taxes to more than one state, there’s generally some sort of credit given by the states for taxes paid in other states so that the total tax burden is not dramatically higher than it would be if you only owed taxes to the more expensive state. Could a system like that work for a synagogue in a way that respected the obligations of interfaith families to support multiple religious organizations without the synagogue explicitly encouraging donations to a different religion?

Suppose synagogue dues are $2000, and suppose the expectation of an interfaith family is to pay a roughly equal amount to both faiths. It seems punitive to expect the interfaith family to pay $4000 in total while the same-faith family pays $2000. But asking the interfaith family to only pay $1000 towards the synagogue while the same-faith family pays $2000 risks considering the interfaith families as second-tier members within the synagogue. Perhaps a 1:3 reduction in dues for contributions to the other faith, up to a maximum reduction of 1/4 of the dues? If an interfaith family contributes $600 to the other faith, then the synagogue dues are reduced to $1800; a $1500 or greater contribution to the other faith means that synagogue dues are reduced to $1500. The interfaith family is still contributing a higher total to religious organizations and close to the same amount to the synagogue as same-faith families, while there is some recognition of the higher total being a potential burden.

Or does it just end up the same as the intimidating process that anyone with limited income faces when asking for a dues reduction, where some random people within your small religious community stick their noses into your family’s finances and you never quite feel like you’re on par with everyone else within the religious community?

Here’s how I would like to approach the synagogue dues: First, how much would we conribute to the synagogue if there were no set dues? If that voluntary amount is higher than the dues, contribute the higher amount. That was easy. If that voluntary amount is lower than the dues, can we stretch a bit and pay the dues without real hardship? That was ok. If the dues really are a hardship, then there should be a clearly-stated dues reduction policy based on some sensible factors like family size and adjusted gross income. (That’s how many governmental assistance programs work.) And then a step beyond that for families with more difficult circumstances. I just think that part of keruv/outreach to interfaith families should perhaps put a dues reduction in the clearly-stated dues reduction policy rather than in the difficult circumstances step.

Precertifications

A brand new feature of our health plan this year is that everything has to be precertified. They didn’t actually tell us about this change until they started denying claims for not being precertified.

So a doctor wants to do a blood test or order an MRI or perform a procedure or prescribe a drug. First someone from the doctor’s office has to find the right way to request that Cigna approve whatever it is. Then Cigna asks for medical records. Eventually the doctor‘s office provides the medical records, and Cigna ponders them for a week. Then Cigna may approve the medical care, or may deny the medical care. If Cigna approves it, then you can move forward one space. If Cigna denies it, well, that’s because they care.

So what happens is that medical care grinds to a halt while Cigna does nothing useful.

From my perspective as a patient, this creates a number of unsolvable problems. I’m actually the one who cares about me getting medical care, but I cannot do anything in this entire process. I cannot ask Cigna to approve anything. I can ask the doctor’s office to start the precertification process, but I am not allowed to be kept in the loop about that process. I cannot get verifiable answers to whether or when the doctor’s office has requested precertification, whether or when Cigna has asked for medical records, whether or when the doctor’s office has provided those records, or whether or when Cigna has actually approved or denied the medical care. I am not notified at any step by anyone, and I cannot receive any written answer from Cigna about any of this process. Cigna’s answers over the phone about precertifications are erratic/random/untethered to reality/completely at odds with answers they may give five minutes earlier or later.

When I beg Cigna to expedite the process, Cigna replies that the doctor’s office has to do the begging. I’ve noticed that doctor’s offices don’t like to beg. They also don’t like to wait on hold, and I have actually seen surgeons waiting for an hour or longer on hold with Cigna.

Cigna will not provide their standards of care, their criteria for approval, or their reasons for denials. When Cigna substitutes their medical judgment for the medical judgment of my doctor, Cigna will not answer any questions or recommend any alternatives.

I’m supposed to have an MRI on Friday, June 20. We scheduled it last Friday, and the doctor’s office assured me last Friday that they would take care of the precertification in time. This evening Cigna said that they do not intend to decide on the precertification until late next week at the earliest. Under Cigna’s preferred timetable, even if they approve the MRI at that point, the MRI cannot happen until mid-July. If they deny the MRI, well, that’s because they care. At which point we have to start some miserable appeals process, or just go to the emergency room.

I had thought that a major concern of health care reform was trying to shift health care away from emergency rooms. Cigna’s precertification process does not apply to emergency rooms, so it pushes care towards emergency rooms.

Both Cigna and the doctor’s offices are able to speed things up somewhat if they treat them as emergencies, which they can only do if they wait until the last minute. So they wait until the last minute, playing chicken with each other. And doing it at the last minute means that we get to plan for an MRI on Friday (take time off work, arrange child care, cancel our other plans) without knowing until Friday whether there was any point in doing that.

And of course the doctor’s office cannot schedule a phone call with the PA about the MRI results until the MRI is completed. And they cannot schedule a follow-up appointment with the PA until the phone call is completed. And they cannot schedule an appointment to talk to the surgeon until the appointment with the PA is completed. And they cannot schedule surgery until the appointment with the surgeon is completed. Just like the precertifications have to be done last-minute, all of these appointments have to be made last-minute. The doctor’s office is entirely complicit in this refusal to allow patients to make any plans, in this refusal to acknowledge that many things in life are much easier with advance planning, and are painfully difficult without it.

It’s a degrading process, and a horrible way to treat people.

Update with a case study of this particular MRI:

We told the doctor’s office last Friday that they needed to start the precertification process. Cigna says today that no precertification request was made until the following Wednesday, two days before the MRI. We have no way to know whether the doctor’s office actually procrastinated that long.

The doctor’s office told us that they sent over all clinical information yesterday. Cigna told us last night that the doctor’s office had not sent over any clinical information. We have no way to know who is lying.

Precertifications might be handled by Cigna or by Medsolutions. Last night, Cigna said that Cigna was handling this precertification. This morning, Cigna said that Medsolutions was handling this precertification. Later this morning, Cigna said that Cigna was handling this precertification. We have no way to know which is true.

The doctor’s office told us this morning that they spoke to Cigna on the phone this morning. Cigna said later this morning that this would be how Cigna knows to escalate (speed up) the precertification, but that it didn’t happen. Cigna also says that they cannot take an escalation request from the patient or anyone other than the doctor’s office, and that they cannot call the doctor’s office to confirm that the request should be escalated. The doctor’s office refuses to call Cigna again until noon. Because proving that Cigna is a bunch of lying assholes is best accomplished through passive-aggressive hostility directed at the patient who is begging you for help.

The medical guidelines for approving a knee MRI that I could find from another insurance company say to approve it for basically any suspected or known knee injury, knee malfunction, or knee pain, because it’s the best hope for seeing what is going on in the knee. Cigna needs detailed medical records because, wait, no, they is absolutely nothing that could possibly be in anyone’s medical records that would suggest that a first MRI should not be approved.

An appeal for sanity

I’m finding the financial insanity of our health plan hard to look away from. Start from the premise that the health plan covers a $6000 medication, taken every 4 to 8 weeks.

Another provider might have a negotiated price of $3000 or $9000. The providers know their list prices, but not their negotiated prices. The health plan knows the negotiated prices, but that information isn’t available to the patient. So much for the patient being able to choose a less expensive provider.

Some patients find out after a year of pointless treatment that the medication is no longer working. Leaving aside the damage to the patient’s health, the health plan has just wasted $39,000 to $78,000. There’s a test that can show ahead of time that the medication is no longer working, but that test costs $300 and isn’t covered by the health plan, so doctors often don’t order it. From both a fiscal and a medical point of view, it should be done every time the $6000 medication is given. Instead, it’s done rarely.

We can appeal the decision not to cover the test, but Cigna requires a ton of paperwork from us and from the lab and from the doctor’s office, refuses to use any information already on file, and refuses to provide any response in the end. I have a confirmation number to that effect from 6/14/2014 of 3406, which I know from experience will do me just as much good as any random number. We can supposedly ask for preauthorization for the test, but Cigna won’t even acknowledge that request (let alone approve it).

How does any of this make sense?

Defensive refills

Doctor prescribes a $2000 bottle of antibiotics. Patient cost is $10, insurance cost is $2000. (Numbers are rounded for simplicity.)

Insurance company, seeking to save money, demands prior authorization and refuses to fill the prescription until hoops are jumped through. Uncertain whether the hoops will ever be jumped through or when, and having been told that the antibiotics should be started immediately, patient grows increasingly concerned as an entire work week ticks by without authorization. When the insurance company finally approves the prescription, the patient fills the prescription and decides to get a defensive refill as well, just in case it is ever needed in the future, to avoid a risk of further dangerous interference from the insurance company. Final cost to the insurance company: $4000.

How could this cost be lowered? Well, the insurance company could skip the prior authorization, which would leave the patient willing to skip the refill if it isn’t needed. Final cost to the insurance company: $2000.

Any improvement possible over that? Well, the insurance company knows that some people only take these antibiotics for 2 weeks, so they could approve 2 weeks at a time without any prior authorization. Final cost to the insurance company: $1000 if only 2 weeks are needed.

Even if a minority of patients take the approach I described and get the defensive refill, there is still a cost to the insurance company in having the review process. The only way this makes economic sense for the insurance company is if they are denying a substantial percentage of these prescriptions. If a lot of patients get the defensive refill, the insurance company has to be denying well over half of these prescriptions. From a medical interference standpoint, it doesn’t really matter whether the insurance company is denying the prescription or if the insurance company is being such a source of frustration to the doctors that the doctors are deciding in advance to not even try to prescribe the drug that they believe is medically appropriate. Either way the patient does not get the drug their doctor wants them to take.

This is not the right way to run a health care system.

Separate meals at the same table

Feeding our family is a little tricky these days, and is continuing to evolve.

Lisa: no grains or starches of any sort, including wheat, rice, corn, potato, sweet potato, soy, beans, gums. No sweeteners other than honey. No banana, no kiwi. “Gluten-free” products almost always use a substitute that she can’t eat. Diet is basically non-starchy vegetables, fruits, meats, eggs, cheese, nuts, oils, vinegars, spices. Caveats: meat that has been injected is usually unsafe (this happens a lot with poultry), marinated items are usually unsafe, shredded cheese and nuts often have unsafe starches added, and even spices sometimes have unsafe starches added.

Michael: no shellfish, walnuts, pineapple. No dairy (including milk, cream, sour cream, milk powder, whey, nisin, and lactose). No red meat (beef, pork, lamb).

David: no tree nuts (especially cashew and pistachio), no mango, no pink peppercorn. We carry an epi-pen for him. We do not currently avoid items processed in a facility that also processes tree nuts. Peanuts and coconut are ok.

We spend a lot of time reading lists of ingredients, and we rarely go out to eat these days.
 
And here’s the biggest problem: unless you’re used to worrying 24/7 about cross-contamination issues, it’s basically impossible to avoid cross-contamination. You drop crumbs into the (no longer) safe food as you pass a roll across the table. You touch a serving spoon to a plate with unsafe food, and then put it into the (no longer) safe food. You spread mustard on a roll using a knife, and then put the knife back into the (no longer) safe mustard jar. And you won’t even notice it.
 
This is difficult for us, and we don’t want to make it difficult for other people or add to our own stress in worrying about all of this. Unfortunately, good intentions aren’t enough. These aren’t cooties or simple dietary preferences. We’d rather not discuss the gruesome medical details, and trust me that you’d rather not think about them.

We would like to be able to eat with other people. We’ve worked out specific foods that we can eat. If you want us to come over for a meal, please let us bring our own food that we can keep separate. We’d be happy to bring some for you as well if our food appeals to you, and just ask you to keep it separate. We’d like to share your table, enjoy your company, hear your stories, and share some laughs. We just cannot break the same actual bread together.

Donating prepaid cell phone balances

We’re getting rid of our old T-Mobile prepaid cell phones soon, and I wasn’t sure what to do with the balances on them. Turns out there’s a comprehensive list of charitable organizations you can donate to via text message (if I can figure out how to send a text message with an ancient Motorola V195).

http://mobilegiving.org/?page_id=43

Greater Boston Food Bank stands out to me, since we often give to them anyway.

Balancing the budget, $23.95 at a time

We mailed an international envelope with $23.95 in postage on it. The post office cancelled the postage and returned the envelope marked “postage due,” demanding another $16.60 because it wasn’t a flat rate envelope. Except that it was.

They marked up the envelope to make it unusable, so we have to repack the order. They marked up the postage to make it unusable, so we have to pay for new postage. The post office should look at what happened, apologize, and cover the postage on the replacement package. But the reality is that the $23.95 is gone, because the only recourse that the post office offers is to fill out a form requesting a refund, which the post office will sit on for months and eventually refuse in the hope that we won’t appeal.

Mistakes happen. This one was that an incompetent postal worker didn’t know the post office’s own range of envelopes, and couldn’t be bothered to read the words “Flat Rate” printed on the envelope. What bugs me isn’t the mistake. It’s that the post office’s policy is to penalize the customer for their worker’s mistake.

Ghosts of evil past

RadioBoston asked what questions people have for Martha Coakley. Here’s one:

According to lawyers all over the area when you were district attorney, you trained a generation of ADAs to lie in court, withhold evidence, and disregard both truth and justice, all to further your pursuit of higher political office. As attorney general, you have quashed investigations into Beacon Hill, allowed insurance rates to skyrocket, and failed to address the mortgage crisis in any way that truly helps homeowners or punishes banks. When you insisted on arguing a case before the Supreme Court yourself, you somehow failed to convince a conservative pro-prosecutor Supreme Court to rule in favor of prosecutors. That ruling is what has now led to the fallout from Annie Dookhan being such a mess. As governor, who would you lie to, lie about, threaten, or lock up in order to improve education, transportation, human rights, and economic opportunity in the Commonwealth?

Here is what I wrote in 2010. I still believe it to be true:

Martha Coakley is deeply unprincipled. She serves her own ambition, and nothing else. She does not believe in the rule of law, or fairness, or justice. She willfully damaged her community as a prosecutor over and over again. She sanctioned child molestation, shielded predators, and persecuted the innocent. And when given the responsibility to hire and train young attorneys, she coached them to lie to judges, conceal evidence, and do everything in their considerable power to destroy people’s lives, innocent or not, in a quest for headlines.

I will not consent to give a person like that my vote.

While I would prefer that political candidates be, on the whole, cut from better cloth than they generally are, I do not refuse to vote for candidates simply because they are thoroughly flawed. I do not refuse to vote for candidates simply because their ideals, principles, beliefs, goals, or actions are at odds with some of mine. I can overlook a lot, but I cannot vote for a person I truly believe is evil. I believe with all my heart that Martha Coakley’s success has been a triumph of evil.

I know that there are many good people and informed people who will vote for Martha Coakley. You, dear reader, may be one of those people. You may believe that Martha Coakley cannot possibly be as bad or dangerous or immoral as all that, or you may believe that there are other concerns which warrant voting for someone who is. If so, please know that I disagree. 

Voting for Carl Sciortino

I’m voting for Carl Sciortino for Congress, and I encourage everyone in this district to do the same. This is not criticism of the other candidates. This is wholehearted enthusiasm for Carl.

I’ve known Carl for many years as my state rep. I actually spoke with him as a state rep before I was redistricted into his district a couple of years ago. I’ve seen him at dozens of public meetings and events, and I’ve spoken with him at length about issues ranging from taxes to transportation to arts funding to CORI reform. He is smart, thoughtful, friendly, and genuine. (That’s not true of enough people, let alone enough politicians.) When I have talked with him about an issue that was new to him, he has listened to my thoughts, gone and learned more, and then gotten back to me. I agree with him on many issues, but more importantly I trust his priorities. He values people, he values transparency, and he values clear and open communication. He is clear about his views without dismissing others.

Carl has also been a very effective state rep. He has been a leader within the legislature on transportation issues, education reform, and human rights. He has been extremely accessible to his constituents, open to talking to anyone. I’ve often written in his name when I was not satisfied with the choices on the ballot for various races. I would love to have him as my Congressman.

Our Congress is currently extremely broken. I’m under no illusion that Carl will be able to fix that. But he will stand up for progressive values without increasing the polarization, he will work to pass and improve legislation that can make it through a broken Congress, and he will be in a good position to help our country become a better country as Congress eventually returns to the important work of governing.

So I’m voting for Carl Sciortino, and I hope you do as well.

A lecture on October 28

Swarthmore President Rebecca Chopp hosts Political Science Professor Ben Berger in a lecture:

"Guilty—with an explanation: Moral engagement and disengagement in democractic life"

Each day we engage with certain moral principles and follow through with appropriate actions. We also selectively disengage from other moral principles. How do these processes work? Should some kinds of moral engagement and disengagement concern liberal democracies more than others? This topic bridges research from political theory, moral philosophy, social psychology, and cognitive neuroscience.

Monday, October 28, 2013
Reception with hors d'ouevres and wine at 6 pm, talk begins at 7 pm

Boston Marriott Copley Place
110 Huntington Ave
Boston, MA 02116

RSVP by October 21 to the Alumni Relations Office at alumni@swarthmore.edu or 610-328-8402.

Early intervention is many things

Early intervention is periodic formal testing of your child, telling you whether or not your child is sufficiently developmentally delayed to qualify for service.

Early intervention is periodic formal testing of your child, telling you whether or not your parenting has been adequate.

Early intervention is seeing your child qualify for services, then learn to walk, then actually start early intervention and have early intervention take credit for teaching him how to walk.

Early intervention is weekly visits to your home where a specialist works with your child on whatever skills you want them to focus on. The specialist answers your questions, offers suggestions, explains their methods, and includes you as a parent in the planning and the activities.

Early intervention is weekly visits to your home where a specialist works with your child on whatever skills the specialist wants to focus on. The specialist undermines your authority in the home and disrupts the nature of your home as a safe space.

Early intervention is weekly written notes evaluating your child, creating an enormous set of paper records that cannot possibly help your child. Early intervention is also being handed written notices telling you your legal rights over and over and over again, as if they can’t believe that you’re honestly not going to exercise your rights to escape from early intervention.

Early intervention is a playgroup with structured activities that you have to fight to get your child into for six months, while they keep promising that admission is right around the corner. Early intervention is where your toddler with excellent motor skills is placed in a group with barely crawling infants. Early intervention is where healthy snacks are fruit punch, cookies, and Froot Loops, where a rule against fruit means serving grapes or jam-filled cookies, where a rule against bare feet means that only some of the kids have bare feet, and where the teaching assistants barely seem to have a clue how to interact with a child. Early intervention is where the group’s daily schedule is written out, posted on the wall, and completely ignored. Early intervention is where the changing table is broken, the carpets aren’t cleaned correctly, and your wallet is stolen. Early intervention is continually dashed expectations and broken promises.

Some days, early intervention is a teacher misjudging your child’s emotional state, refusing to respect your knowledge about your child, and silently disregarding your instructions.

Some days, early intervention is a teacher telling you that you’re the one holding your child back. What a nasty thing to tell a parent, no matter whether it’s true.

Can't get away from the news

So the House of Rs has shut down the government, hurting a lot of people. Possibilities: 1. They think they'll gain a long-term political advantage by doing this, and that's worth hurting a lot of people. 2. They think they'll actually win some or all of their latest demands, and that's worth hurting a lot of people. 3. Shutting down the government and hurting a lot of people is not a means to an end; this is the actual goal.

I don't really care which of these is true. I just want to go visit Acadia National Park and forget about the news. And I can't, because the national parks are all closed.

Questions that should not be hard for a health insurance plan to answer

Is a lab in-network for my insurance plan?

CIGNA's answer: Maybe. There's no way to know for sure, unless you use Quest. See what happens. Depends on who decides to bill under which provider number. Answers from the lab or from CIGNA in advance do not correlate to how the claim is processed. No way to obtain a definitive answer that you can then rely on.

If a lab is in-network, should the insurance plan cover the out-of-network pathologist claim tied to that lab as if the pathologist were in-network?

CIGNA's answer: No. Yes. Maybe. No written policy.

If a lab is not in-network, should a claim be paid as in-network if an in-network doctor chose them?

CIGNA's answer: No. Tough luck, you should always check on which lab your doctor is using for every test, even though we offer no definitive answers on whether any given lab is actually in-network. But no written policy saying this.

If a lab is not in-network, should a claim be paid as in-network if nobody in-network can provide the same test?

CIGNA's answer: No. Yes. Maybe. Could fall under medical necessity, but that would probably require an appeal and massive cooperation from your doctors.

If a lab is not in-network, how can the insurance company say that the lab failed to follow insurer guidelines and therefore the patient owes nothing to the lab?

CIGNA's answer: Um, well, that's what the EOB says, but we might change that later, and there is no way to guarantee finality.

If a lab is not in-network, how can the insurance company apply a discount to the amount that we owe the lab?

CIGNA's answer: No answer.

Does a payment to an out-of-network provider cross-accumulate toward the in-network individual deductible? Toward the in-network family deductible? Toward the in-network individual out-of-pocket maximum? Toward the in-network family out-of-pocket maximum?

CIGNA's answer: Yes to all of these. But not until the out-of-network claim is actually processed, even if that takes much longer than any other claims. And we won't give this information in writing.

If the order of claims affects how much the patient owes, should claims be processed in order of date of service? In order of date of claims submission? In whatever order most benefits the patient? In whatever order most benefits the insurer?

CIGNA's answer: In order of date of claims submission, subject to a lot of random variation, with hints of an internal policy of rigging the processing order to benefit CIGNA. No written policy, not even an internal written policy answering this question.

If claims are processed in the wrong order, how can that be corrected? Can $1000 that the insurer wrongly told the patient to pay to 20 different providers be reimbursed by the insurer directly to the patient, since the providers have already been paid? If the insurer now sends payments to 20 different providers that duplicate payments that the insurer already told the patient to pay, can we get a list of those payments? Can amounts that the HRA wrongly paid on the patient’s behalf be reimbursed directly to the patient? Restored to the HRA?

CIGNA's answer: Claims are always processed in the correct order. Mistakes cannot happen. You can always appeal, but you cannot reference any written policy about how claims should be processed. Duplicate payments to in-network providers can only be sent by CIGNA to the providers, with no tracking of those payments available to the customer. If an amount was wrongly paid by the HRA, the customer must convince the provider to refund the HRA payment to CIGNA, who will then theoretically put the money back into the HRA account, where the customer can then submit manual requests for the HRA to send payments to other providers. So if CIGNA told the HRA to pay Doctor A and told the customer to pay Doctor B, and then CIGNA later decides to pay Doctor A themselves, the customer must convince Doctor A to refund the HRA payment to CIGNA, wait for CIGNA to put it back into the HRA, then ask CIGNA to pay Doctor B with the HRA funds, wait for that payment to go through, and then convince Doctor B to refund the customer's original payment to Doctor B. Because what could go wrong?

The above questions are really about how the health insurance plan should work. Then there’s the parallel questions of how it will work, since practice and theory differ. It seems like somebody should be able and willing to provide authoritative answers to at least some of those questions, in a way which we can then insist that the insurer abide by those answers. But, well, no.