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.

Roof notes

(with links I want to save)

Because the solar companies told us we need to deal with our roof, we started learning about roofs. They’re much more complicated than I thought. The big problem for us is the chimney flashing, which is not in great shape. We don’t want more lead on the house, but lead flashing is the standard choice in these parts. The roofer we were going to use won’t consider any alternatives. Lead flashing stays much more intact than lead paint, but it can have some runoff, and installation and removal both are much more problematic than commonly acknowledged. And where our chimney is, any lead dust running off from around the chimney (from cutting the lead, deburring it, grinding it out, or just continued degradation from environmental exposure) will go straight into a very small garden that we want to be working in.

The other good choices seem to be removing the chimney entirely or using copper flashing. (Copper isn’t great to ingest, but it’s not as bad as lead, and there’s a lot of copper in roofing shingles anyway to reduce algae growth.) I’m not sure why nobody considers zinc. We can’t remove the chimney until we change out the furnace (planned for the next few years), the water heater (as soon as feasible), and the fireplace (need to learn more). But it would make a lot of sense to remove it: it’s usefulness is declining, maintenance is a giant expensive headache, and it’s an enormous roof penetration that coincidentally makes house fires worse.

We might talk to GF Sprague, Ranch Roofing, or someone else recommended on the Arlington List. We have three quotes from other roofers, only one of which seems sufficiently detailed.

I’d love to rebuild the front porch and dormer over it at the same time, but we can’t live through that kind of construction with a toddler. And we still won’t be able to make our house look like this one.

For solar reflectivity, asphalt shingles vary from terrible to bad. Medium gray is pretty close to light gray in reflectivity, and is not as terrible as very dark gray or black.

If we ever do more work on the inside of the house, there’s some ideas at aMortonDesign, Clarke Carpentry, and Second Life. Or we could do more ourselves with help from Mr. Pete. We’re adding some shelving to my office, but I don’t really want to do more interior work anytime soon.

Shop class

Solar, the postscript

The Massachusetts last chance auction for SRECs was completed last week. This is the mechanism that SunBug described to me as a price floor for SRECs, a mechanism to guarantee that SRECs would always be worth a minimum of $300 each. It’s an annual fixed price auction at $300, but Massachusetts forgot to require the utilities to actually buy the leftover SRECs at that auction.

There were 38,866 SRECs available. How many cleared? All? Almost all? 75%?

3.

Not 3%. Just 3.

They sold 3 SRECs at the last chance auction. Out of 38,866.

Maybe it looks better in dollar figures. The state put a lot of work into auctioning off $11,659,800 in SRECs. The utilities collectively purchased $900. The state probably spent two to three orders of magnitude more than that to run the auction.

The state did jump in and announce that they were buying all the rest of the SRECs themselves, in a one-time gimmick designed to shift everyone’s embarrassment and anger down the road a year. And they stated very clearly that they won’t do that again.

So there you have the final word on the state’s price support mechanism for SRECs. It was a colossal failure.

If you’re planning on putting in solar in Massachusetts, don’t do it based on fantasies about how much income you’re going to get from SRECs. The state might change the rules, but as things stand now there is no price floor. The folks saying that a long-term target of $150 per SREC is reasonable look a lot more plausible now.

Opinions, not facts, about the candidates for Medford City Council

Medford City Council elections are coming up, sadly. Here are the candidates, complete with my opinions or the opinions I’ve heard from others:

Michael Marks (incumbent): the best of a truly terrible group of incumbents
Breanna Lungo-Koehn (incumbent): somewhat harmless
Paul Camuso (incumbent): sometimes harmless
Frederick Dello Russo, Jr. (incumbent): desperate to appear harmless
Robert Penta (incumbent): this is the lunatic who gets Medford City Council into the papers for all the wrong reasons
Rick Caraviello (incumbent): the new guy, anti-Green Line
Robert FitzPatrick: clearly the best candidate
Adam Knight: can’t find any actual policies, though he appears pro-labor
Mark Crowley: some good ideas, but he must know he’s being completely dishonest about property tax rates as his leading issue (we care about how much we pay, not about the calculation that got us there)
Robert Cappucci: prominent local Republican
Neil Osborne: appears to have the full support of Bill Wood and Carolyn Rosen, the worst people in Medford
Jeanne Martin: goes on endless incoherent public tirades, frequently uses "liberal" as an epithet, vehemently opposed to just about everything
Jim Morse: writes a lot about local issues, an anti-development and anti-Green Line crusader

Now let’s create an interesting and smart Medford City Council. Here’s a slate: Ken Krause, Sharon Guzik, Doug Carr, Laurel Ruma, Dee Morris, John Roland Elliott, and Allison Goldsberry. Why are none of these people running?

I’ll be loyal to any brand that deserves it

It’s been an exciting month on the appliances front.

Our Samsung refrigerator (less than 2 years old) has been behaving badly for months. The freezer frosted up constantly, the freezer glides weren’t working correctly, and Samsung was being a real pain to deal with. Lisa and I finally did good cop/bad cop and got Samsung to send a tech to do a warranty repair, and two weeks ago the tech finally replaced a freezer glide and admitted that it was defective. Problem solved.

Two hours later, the Kenmore gas dryer (well over 15 years old) stopped heating up. Lisa’s dad (a mechanic) had been planning to visit later in the week, so we waited for him to show up to start taking things apart. The first YouTube video for the dryer model showed how to check the various electrical components in the back of the dryer for continuity, including a fuse. Bingo. The fuse was busted, Sears had the $16 part only 6 miles away, and now the dryer works.

So we decided to tackle the GE gas range (8 years old). The oven had been whooshing since the winter, and had been getting slower and slower to get up to temperature. And the burners had been pulsing if the oven was on at the same time, which didn’t look right at all. Some web research suggested that it could be the oven igniter, and some further web research turned up some pretty clear video and photos about how to replace the igniter. Amazon had the part for $26 (far better than $93 direct from GE for the identical part), and the second time they shipped it to us the igniter arrived intact. And now our range works.

Yesterday we discovered that the large Frigidaire window air conditioner (7 years old) taking care of our entire first floor had gotten its drain plugged up, and had damaged some floor, some wall, some carpet, and the window. We’re not fixing the air conditioner; replacing it seems like the better plan.

A house can be unending problems, and that can get terribly overwhelming. But the satisfaction of reducing the list of problems and fixing some of those problems ourselves is enormous.

Solar, part 3

A company called SolarFlair is doing the Solarize program for Newton and Brookline, and offering much better base pricing and a 10-year labor warranty rather than SunBug’s 5-year labor warranty. The base pricing goes down to $3.69/watt with SunBug if enough people sign up, while SolarFlair starts at $3.69 and goes down to $3.14. Of course, I don’t live in Newton or Brookline. I wonder how SunBug got the Solarize Medford contract. Perhaps the adders for better panels and other upgrades cost a lot more with SolarFlair.

Aside from the massive uncertainty built into the SREC program (a 5kW system might be worth anywhere from $8000 to $25,000 in SRECs over the next 10 years, or possibly even less than $8000), it turns out we cannot get an enforceable long-term agreement with the city to be able to trim the city-owned shade tree if it grows too tall. Any future city government would be able to unilaterally revoke any such agreement or permit.

And we’d need to add snow guards lower down on the roof to deal with the tendency of solar panels to release their snow cover in one big whoosh, since that avalanche of snow from our roof configuration would be coming straight down at our front steps and our poor abused garden.

The final numbers as I understand them: We could spend about $24,000 up front for a 4.9 kW system, get $3900 back in a state rebate, $1000 back in a state tax credit, and $6000 back in a federal tax credit. That’s a net cost of $13,100. We’d generate about $600/year to $800/year in electricity at today’s 14 cents per kWh. We’d also earn $1000 in SRECs per year, or maybe $1500, or maybe $600, or possibly less or more. Conservative numbers would be $1200 per year payback, and that assumes we don’t have shade problems. If electricity prices go up a lot and the state fixes the SREC price support to be a true floor, the payback could be much better. But the conservative numbers don’t justify the costs right now.

The way to make the economics work are to put up more and cheaper panels, and treat the credit on the roof work as a deduction from the solar. So we spend $20,000 up front, get $4000 back in a state rebate, $1000 back in a state tax credit, and $8000 back in a federal tax credit. That’s a net cost of $7000. At $1200 per year payback, that looks worth it. Barely. And that’s not worth the continuing headache.

Next year solar costs will be different, the SREC program will be different, and some of what I’ve learned will no longer apply. And so it goes, round and round the sun.

Solar, part 2

Well, we got our quote from Sunlight Solar. They are substantially more expensive than SunBug’s proposal, but I also learned a bit more about SRECs and solar finances.

Both companies agree that SunPower panels are much better than everyone else’s panels at the moment. SunBug wants to use the previous generation panels, and Sunlight Solar wants to use the current generation panels.

Sunlight Solar projects about 7% less production than SunBug, which seems reasonably consistent to me given the number of variables.

SunBug said that there’s a price floor of $300 on SRECs. Sunlight Solar says that there is no floor, because the last chance auction isn’t guaranteed to work. Turns out that’s true, which substantially changes the finances. And I’m not thrilled about SunBug lying to me on a huge issue like this. Some folks in the industry think that the last chance auction price of $300 is going to act as a ceiling rather than a floor, and that $150 per SREC is a more likely long-term price. That’s a loss of about $8000 over 10 years from SunBug’s numbers.

And even worse, the current unpredictable SREC scheme is only guaranteed to be available for systems that are approved for interconnection by December 31. After that, systems will likely earn even less with SREC 2, whose rules aren’t set. SunBug won’t guarantee installation by December 31, and is lying to customers about the implications of that deadline.

Meanwhile the city is not being at all cooperative about potential future shade problems from their tree. I would have expected them to understand this issue, since they’re pushing the solar program city-wide and many houses have city-owned trees at least in front.

I still want to install solar if it’s financially reasonable to do so and if we can clear the other hurdles. But the forecast isn’t very sunny.

Solar, part 1

Medford is doing a community push for solar, which convinced me to take another look at solar for our property. The city’s chosen installer is SunBug, and I’ve gotten a proposal from them.

Choosing an installer is tricky. There aren’t a lot, and most haven’t been in business very long. But since they are going to be messing with your roof and your electrical system, you want someone good. There aren’t a lot of reviews. You can see an Excel file of all the companies who have done projects in Massachusetts in the past few years that qualified for a state rebate program. Brightstar Solar gets great reviews, but isn’t doing installations in Medford. Sungevity was very hard to talk to in 2012, and Next Step Living has frighteningly bad reviews, so I’m skipping those two. I’ve been waiting to hear back from Blue Selenium, and Sunlight Solar is coming next week to do a site evaluation.

Direction matters. South would be optimal. On the map, it looks like our unshaded roof faces ESE. SunBug thinks it’s close enough to SE that we’ll be ok.

Pitch matters. Our roof is 45 degrees, which is a decent compromise between wanting steeper in the winter and less steep in the summer.

With both direction and pitch, I’d expect to find decent curves showing the dropoffs in production and calculators that let you see the results. I haven’t found those yet. But solar companies must be using those.

Shading matters. A little shading can have a huge detrimental effect on production since solar panels are wired in series (both within the panel and in a string of panels). The only shading we really have to worry about would be if the tree in the park next door gets much taller, but the problem is that we don’t have the right to trim that tree if it does. Perhaps the city would like to agree to trim that tree if it starts to shade our solar panels?

Roof condition matters. SunBug told us we have to redo our roof before we can install solar. I expect other solar companies will tell us the same thing. We have no leaks, so this is sooner than we would replace the roof otherwise, but roofs don’t last forever.

The electrical panel matters. SunBug told us we need to install a subpanel or redo our main panel in the basement to install solar. My idea of putting a subpanel in the attic to make this easier is apparently not a great idea because the attic gets very hot in the summer, which isn’t great for the wiring.

The choice of panel matters. We can produce a lot more power if we use SunPower 327-watt panels than if we use typical 250-watt panels. The downside is a bit more up-front cost.

Financial assumptions make a huge difference. What will happen to the cost of electricity over the next 10 years? What’s the opportunity cost of the investment? Is SREC income taxable? (At the moment there’s a good argument that SREC income is not taxable, since it’s less than the cost of putting in the panels. But it makes a big difference if it becomes taxable, since that’s the bulk of the payback over the first 10 years.) How does depreciation on the system work with my home office? Will my insurance cover the solar panels? Will the system increase or decrease the house’s value? (Looks like a modest increase in the short term, but my guess is that it won’t matter in the long term.)

Financing matters. About 2/3 of new systems are leased rather than owned. Since we may want to sell in 5-10 years, and leasing makes that harder, we need to own the system.

The roof geometry of the front of our house is terrible for curb appeal. Will a monolithic solar array on the top section make that better or worse? How will a different roof color affect the appearance, since we can choose a different color when we reshingle?

But I like the idea of having more of our electricity come from solar, and this is the step we can take towards that. It’s not an ideal site, and there aren’t ideal conditions here, but it still may pay off in about 7 years (based on some reasonable assumptions). That’s pretty good.

Not buying it

In “The Health Insurance Shell Game,” Nortin M. Hadler and Janet Schwartz lay out some of the insanities in the way we handle health insurance in this country. But towards the end of their post, they start discussing the fact that some treatment options are less effective or ineffective, and suggest a good way to reduce health care costs would be for health insurance to refuse to cover various treatment options.

We should be offered a “high efficacy option” at lower cost than an “any efficacy option” and no one should be offered an option that indemnifies for interventions that have been studied and cannot be shown to offer a clinically meaningful benefit.

There are a few problems with this line of reasoning. First and foremost is that health insurance already refuses to cover a variety of treatments, as many patients with complex or difficult conditions know, and this has not solved the terrible excesses of health care costs.

I disagree with the notion that we can clearly delineate a large new set of treatment options which “cannot be shown to offer a clinically meaningful benefit.” Evidence-based treatment protocols can provide valuable guidance in prioritizing treatment options in the absence of further information, but many patients are not approaching their health care treatment as a blank slate. You (or your doctor) may already know that the treatment most likely to help an arbitrary individual based on statistics will not be effective for you. A study showing that a treatment is ineffective for many or most people does not establish that it cannot help some specific individuals, and we often don’t have a way to determine which individuals a treatment will help without trying it. Medical studies which insurance companies already rely on to deny coverage are hardly infallible; in fact, they are rife with fraud and conflicts of interest, and results often cannot be replicated or directly contradict other studies. When studies of well-known treatment options are repeated, the measured effectiveness appears to decline without a clear explanation. And when we study placebos, a treatment option which we know cannot have any clinically meaningful benefit, we discover that placebos can have significant clinically meaningful benefits.

But none of this matters when we are working to convince you, the beleaguered consumer, that the reason your health insurance premiums are so high is that there are lots of other people pursuing useless treatments. Those other people are spending their days at the hospital for fun, and wasting your money to do it. And when you are denied coverage for a treatment, you should be grateful because it wouldn’t have helped anyway.

If you buy this argument, I’ve got a great insurance policy to sell you.

Waiting for Godot has so much talking

8:00 am: Arrive at courthouse along with other potential jurors. Building is locked. Moral: Do not arrive early.

8:15 am: Courthouse opens. Anyone claiming to be called for jury duty is sent into the building, skipping security entirely. Social worker is yelled at for trying to enter the building, having stupidly assumed that seeing people entering a building means that the building can be entered by people. Moral: Wait for instructions.

8:30 am: Court officer shows up in the jury room to check people in.

8:40 am: More potential jurors arrive, having been waiting at the front of the building since 8:20 with no instructions from anyone there. Court officer scolds them extensively for not having arrived by 8:30. Moral: Do not wait for instructions.


8:45 am: A potential juror tries to ask a question. Court officer scolds her. Moral: Do not ask questions.

8:50 am: Court officer tells us that the judge will show up at 9:00 to say hi, then we’ll watch a video, then she will send us on break from 9:30 until 10:15.

9:10 am: Judge says hi and leaves, court officer starts the video and leaves. The video trumpets the diversity of the jury pool, carefully showing racial and ethnic diversity. 19 white people in the jury pool covertly glance at the only non-white person in the jury pool.

9:30 am: The court officer does not return. Half the jurors leave, deciding we must be on break now. Moral: Do whatever the hell you want, because nobody cares any longer.

The only reading material in the room is four small signs, four romance novels, a variety of magazines from 2011 and 2012, someone’s confidential juror questionnaire, and court paperwork intended for a defendant.

10:30 am: An attorney and client enter the clearly identified jury room, stare at us for a while, and leave. Nobody speaks.

10:45 am: There is a loud despairing wail from the hallway outside the jury room. Nobody blinks.

11:00 am: Court officer pops her head in to tell us that she is not there to tell us anything.

11:15 am: I greet the person who has been sitting next to me for the past three hours. As far as I can tell, this is the first and only conversation between any of the 20 people in the jury pool. He was on the jury for a federal trial a few years ago that went on for four months.

11:30 am: Someone in the hallway outside the jury room starts sobbing.

11:45 am: Court officer reappears and tells us all to go home.

The standard you walk past is the standard you accept

This is how scandals should be addressed: head-on, with clear statements and strong principles.

Customer service

I’ve had a very strange experience dealing with Citizens Bank. Someone else wrote a check for $1600 on their account, and Citizens Bank decided to take that money out of my account instead of the correct account. The check image on the statement shows a different account number on that check, so this is a rather obvious bank error.

I’ve spoken to three people at Citizens Bank about this. All three say that this is clearly an error, that Citizens Bank will fix this in a couple of days now that I’ve pointed it out to them, and that Citizens Bank will reverse the low-balance monthly fees that this caused on my account. One person who claimed he was calling from the Chairman’s Office to apologize implied that I must know the person who the check was written to, either failing to comprehend the error or accusing me of attempting to defraud the bank in a truly bizarre manner. Another person first tried to claim that the low-balance monthly fee was still my responsibility, not caused by the Citizens Bank error. And all three said that they could not possibly put the $1600 bank in my account immediately. None seemed at all surprised by the error, or particularly concerned about it.

If I were working for Citizens Bank, I hope I would take a different approach. First, apologize profusely, and say that this error is extremely rare and unacceptable. Second, correct the error immediately. Third, assure the customer that the bank will take care of any fees caused by this error. Fourth, assure the customer that the bank will confirm all of this in writing on the next business day, and ask the customer whether they would prefer to receive that confirmation by mail, fax, or email. That seems like the bare minimum. Going beyond that, I’d like to see the bank offer to waive the fee to mail printed statements on this account, since any sense of trust the customer might have towards Citizens Bank has clearly been misplaced violated. Having a reverse fee schedule for this sort of bank error would improve the sense that the bank is operating in good faith—if they want to charge me $9.99 for not having as much money as they would like in my account for a month, they could pay me $9.99 for having wrongly taken money out of my account. Assign a specific person to take full and direct responsibility for seeing that the error is corrected, and give the customer that person’s contact information. And finally, ask the customer whether there is anything else the bank can do to keep the customer’s business.

And Citizens Bank, if you really want to convey a sense of competence and restore trust, stop calling your customers and asking for their account numbers, social security numbers, or birth dates. That just shows that you neither understand nor care about helping your customers keep their personal information any more secure than you keep their money.

Baby products we have loved

Lotus Travel Crib
http://www.amazon.com/Lotus-Travel-Crib-Portable-Playard/dp/B00AKKDSNG
Lightweight, yet no weight limit. Mesh sides all the way down for maximum airflow.

Fisher Price Rainforest Jumperoo
http://www.amazon.com/Fisher-Price-K6070-Rainforest-Jumperoo/dp/B000LXQVA4/
Stable, durable.

Tiny Love Gymini Bouncer
www.amazon.com/Tiny-Love-Gymini-Bouncer-Yellow/dp/B003GAMMN4/
Unlike other bouncy seats, the toy bars move to the sides to make it easy to put the child in and take him out.

Kolcraft Wonderbug
http://www.amazon.com/dp/B00499DU1O
Seat spins. A safe place to stash a baby while doing other things.

UppaBaby Cruz
http://www.amazon.com/UPPAbaby-0071-JKE-Cruz-Stroller-Jake/dp/B0051Y1G4E/
Enormous storage basket. Seat can face forward or back.

Daydream: The Friday Night Service Social Club

Gather a committed core of 6-10 people who regularly do every component in order to get this off the ground. The core means never having too few people to make the evening a bust.

On first Fridays, the host house opens at 5:30 for a quick Friday night service starting at 6:00. (Random idea: instead of a d’var, take a few minutes before the Amidah to let everyone say something they accomplished or hope to let go from the previous week or something they are looking forward to in the following week.) Dinner to follow starting at 7:00, winding down at 9:00. People beyond the core are welcome to join for services and/or dinner as they wish.

On third Fridays, choose a service at a different shul every month (perhaps alternate reform and conservative), followed by dinner back at the host house. For 7:00 pm or later services, gather at the host house for appetizers and then carpool together. For earlier services, meet at the service. People beyond the core are welcome to join for services and/or dinner as they wish.

We get to have our own service once a month. (Anyone who wants to lead is welcome to, and I’m happy to lead as a default.) We can print off some extra Friday night service books from a local Hillel that recently put one together with full transliterations. We get to see what services are like at different shuls without ever being the only newcomer at a service and without having to make our own individual decisions about going somewhere. We get to have a group Shabbat dinner together twice a month. That would work for me.