Here are the rules: No nuts, no mango, all kosher. This list should grow over time.
Playstead Park is today in the condition that Cummings Park was in six years ago: graffiti, vandalism, broken equipment, trash everywhere. The discussion about it on Facebook is heartbreaking. Many people want the playgrounds maintained, want the damage fixed, and want the vandals caught and punished. None of those people work for the City of Medford.
The police department is responsible for preventing the vandalism and catching the vandals. They refuse to patrol the parks, refuse to install video cameras, refuse to send officers when they are told that vandalism is occurring, and refuse to investigate. Whose fault is that? It’s the fault of the individual officers who refuse to do their jobs, the police administration who refuses to exercise any control over the police department, the mayor who oversees the police department and sets the city budget, and the city council who approves the city budget. If you want this to change, show up at community police meetings on the first Wednesday evening of every month at the police academy and say that you want the police to start doing their jobs. If you want this to change, take photos of the damage and show up at City Hall, demand to speak to the mayor, and tell him that you demand he instruct the police to start taking care of the parks.
The parks department is responsible for repairing the damage and maintaining the parks. The head of the parks department is Mike Nestor. The parks department is part of the Department of Public Works (DPW), and they all report to the mayor. The parks department does not repair most damage and does not maintain the parks. Whose fault is that? It’s the fault of the mayor and the city council, who jointly control the city budget. Many DPW employees are well-intentioned and hard-working, but the department is understaffed, underfunded, and has been given other priorities. If you want this to change, call DPW every day with complaints about specific damage at specific locations in the parks. If you want this to change, take photos of the damage and show up at City Hall, demand to speak to the mayor, and tell him that you demand the parks department start taking care of the parks. If you want this to change, do not vote for any incumbents on the City Council.
What can you do today? Voice your displeasure to City Hall. Call the mayor, call DPW, call the police, call every member of the City Council. Be clear, firm, and specific about what you want them to do. Keep calling until you get what you want.
What can you do on Tuesday? Vote, and do not vote for any incumbents for City Council. The current City Council is fully aware that the parks are not maintained and they are comfortable with that. We need a new City Council.
What can you do in the longer term? Keep voting, and do not vote for anyone who has held public office in Medford recently. Encourage new people to keep running for office, and pray that we get someone new to run for mayor in 2017, since 2015 is just a race between a current member of the City Council and a former member of the City Council. Support an override to increase the city budget to invest in our city. Support a change in the city charter so we do not leave all of the power in the hands of the mayor with no power in the hands of the residents.
DPW can repair equipment, can clean the parks, and can also hire contractors to do both of those tasks. The mayor can ask the county sherriff’s graffiti removal unit to come remove graffiti. (There’s no charge for that, and it baffles me that the mayor refuses to use their service and instead leaves our city covered in graffiti.) The police can patrol the parks, can remove people at night when the parks are closed, and can arrest people they catch vandalizing the parks. These things are all possible, but they will not happen routinely until the city government changes.
I’ve done everything a resident can do. I’ve called the fire department when items in the park were set on fire at night, which used to happen with surprising frequency. I’ve called a homeless services agency when a homeless person started staying in the playground. I’ve called DPW and the parks department, I’ve emailed DPW and the parks department, and I’ve shown up at DPW in person. I’ve gotten a mix of rude answers and polite brush-offs, and occasional action when I’ve emailed Mike Nestor. I’ve shown up at police community meetings, spoken with individual police officers and police administration, and called the police when I’ve seen vandalism occurring. I’ve gotten a mix of rude answers and polite brush-offs, and occasional promises of increased patrols that rarely actually happen. I’ve been cursed at by police officers on the phone and threatened by police officers in person. I’ve gone to a Parks Commission meeting, which was utterly useless for action on playgrounds. I’ve contacted the county sherriff’s graffiti removal unit directly, obtained the form for requesting their services, filled it out and given it to City Hall to act on. That last action embarrassed the city into actually removing some graffiti themselves. Once.
My one real success was around six years ago. After over a decade of complete neglect of Cummings Park by the city, which was in at least as bad shape as Playstead Park is today, I went to City Hall. I brought some large color photos of the damage, and demanded a meeting with the mayor. He called in the head of DPW and the police chief, and we all sat around a table while I laid out their decade of neglect, showed them the results in color, and told them that it was simply unacceptable. They acted surprised and appalled, and within a week at the order of the mayor, DPW repaired and replaced the broken equipment and broken structures, and the county sherriff’s graffiti removal unit came in and removed the graffiti. The police actually responded to a few phone calls in a professional manner for the first time in over a decade, and explained to a number of teenagers that the playground was no longer an acceptable place to drink and do drugs at night and that tearing apart the park equipment was no longer an acceptable activity. That turned out to be enough to turn things around. Within the next couple of weeks, little children started using Cummings Park in far greater numbers. (It used to be largely abandoned during the day, and with good reason.) Parents started contributing toys and play structures to the playground. (This had not happened in over a decade, but it started then and has continued for the past six years.)
The cost is that we have to keep volunteering our time. We have to call the police, clean up garbage, call DPW for continued maintenance, report damage and graffiti and vandalism, throw out toys that are broken beyond usefulness, and trim weed trees. We have to put up with frequently unprofessional and hostile responses from the police and DPW, and put up with complaints and threats from the minority of neighborhood residents who would prefer to see the park go back to falling apart. But we’ve seen how bad it can get, and we’ve seen how much better it can be, and we made our choice. Any parent in Medford knows (or should know) Miss Andrea at Medford Family Network. She runs playgroups that go around to all of the city parks, and if you ask her, she will tell you that all of the parks need that sort of care and attention from neighbors.
A functional city government would not rely so heavily on us to do their jobs. But that’s not the city government we have, and it won’t be until more Medford residents wake up, realize that the deplorable condition of much of our city is not inevitable, realize that the unprofessional and hostile way that city agencies interact with residents is not inevitable, and demand both a change in attitude and increased investment in our city.
The city could make Playstead Park look ten times better tomorrow (and will if you scream at the mayor loudly enough), but until enough neighbors take on enough responsibility themselves and/or the city government changes, it will all be torn apart again in a matter of weeks or months.
Our basement furnace heats the basement as well as the house. We like it that way, since it keeps the basement at a reasonable temperature.
Part of the way it heats the basement is through a series of 150 micro-vents in the ducts, also known as leaks. Heating contractors want to seal all the leaks and put in a normal vent for the basement, which would certainly give us more control over how much heat we put into the basement if we ever wanted to change that amount. What surprises me is that the heating contractors all claim that this will make our system much more efficient.
I think it’s because they cannot get past viewing the leaks as waste heat, even if the leaks are actually putting the right amount of heat where we want it. If the new vent puts as much heat into the basement as the old leaks, then the furnace will still be using the same amount of energy and the basement will still be receiving the same amount of heat. The system therefore cannot be more efficient.
The furnace itself is currently operating at an unknown efficiency level, which makes it hard to know how much energy we would save by replacing it with a higher efficiency furnace. The current furnace could in theory last another 10 years. The current furnace is no better than 80% efficiency, and we could get one that would be 95% to 97% efficient. That would lead to a 16% to 18% savings on our gas bill, which would have been a $300 savings last winter. Gas prices fluctuate quite a lot, and it’s hard to know what they will do over the next 10 years. Over the past 10 years, it would have meant saving anywhere from $200 to $500 per year. A guess would be saving at least $3000 over the next 10 years? If the furnace is actually 70% efficient (either because it’s older than we can prove or because efficiency drops with age), then the savings would be 60% more: a guess of at least $4800 over the next 10 years.
Sila wants $10,000 to replace the furnace and add a good filter. Papalia wants $6800 to replace the furnace, $1300 to add a great filter, and $3200 to replace all the basement ducts. Online info suggests that replacing the furnace is only supposed to cost $3000 to $4000, so I’m not sure why the quotes are so much higher.
After a long time with very few children, our synagogue now has many kids, and is going to start having its first Bar and Bat Mitzvahs in a year or two. (Hold the date for David’s Bar Mitzvah, by the way: 12/14/24.)
Some of those kids may continue with some Hebrew School, but 5 years later they’ll be going off to college, and I’d like to support the kids continuing to practice Judaism at college and keep their families connected to the shul. Some families tend to drop synagogue memberships after the Bar or Bat Mitzvah, and having a sensible program for supporting kids in college might help keep those families connected for longer, particularly when finances get strained by college tuition.
Lots of organizations give scholarships to college kids, so we could look at that idea. It would have to be significantly less than the dues revenue coming in from those families, or funded separately somehow. Should it be tied to taking Jewish Studies classes?
Assistance with going on a birthright trip to Israel?
Gift certificates for Jewish books? Kids still read in college, right? The PJ Library program is great for little kids, and we could create a college version.
Care packages? Shabbat candles and candlesticks (if the college allows candles), Chanukah candles and menorahs, Passover seder kits, mezuzah for the dorm room door, apples and honey — there are lots of possible needs that could be met. Would we ask parents to cover the cost? Should the shul provide or subsidize everything? Some kids will connect with the college Hillel, which will meet most of those needs, but others won’t. Do we focus on items for the student by themselves, or items they can share with fellow students?
As part of joining the board of my synagogue, I was given a copy of the bylaws. Some items of interest to me as a Jewish parent with a non-Jewish spouse, jointly raising a Jewish child and both being active in synagogue activities:
Article III, section 1: “Any person of Jewish faith and the spouse or committed partner of such person (whether or not he/she is Jewish), who are at least 18 years of age, and willing to support the principles and objectives of the Conservative movement, are eligible to become a member of the synagogue.”
The phrase “person of Jewish faith” can include people who are not halachically Jewish under the rules of the Conservative movement. I’m happy about that, since it includes any self-identified Jew who is ok with the Conservative movement without worrying about matrilineal vs. patrilineal descent, details of conversion as a child or as an adult, bet din paperwork, etc.
Only adults are members. My child is not a member. I guess I was never a member of my shul growing up, despite having attended services religiously, having led services, having taught and tutored in the Hebrew School, having worked in the shul office, and having participated in the youth group. That seems a little odd. It feels like children should be considered members (at least non-voting members) if they are part of a family membership.
Cigna Carelink is a problematic arrangement between Cigna and Tufts Health Plan. All medical claims go to Cigna. For claims in most states, Cigna uses Cigna’s network and Cigna’s pricing. For claims from Massachusetts providers, Cigna uses Tufts Health Plan’s network and Tufts Health Plan’s pricing. So the claim comes in to Cigna, Cigna sends it to Tufts Health Plan to process and assign a price, and then Cigna gets the relevant info back from Tufts Health Plan and Cigna generates the EOB and sends payment.
As a Cigna Carelink customer, I can only talk to Cigna. I cannot talk to Tufts Health Plan.
Tufts Health Plan has just priced a simple claim for us three times. The billed amount was $156.00 for seeing a doctor. The first two times, Tufts Health Plan priced the claim at $90.59. The third time, Tufts Health Plan priced the claim at $138.54.
When you provide the same input, you should get the same output. This is a single claim, with no change in the patient, health care plan, date of service, location of service, provider ID, procedure code, or diagnosis code. Why are the numbers changing?
This is not the first time I’ve seen erratic pricing and processing by Tufts Health Plan. I called Cigna today and asked why the pricing by Tufts Health Plan seems to be assigning random numbers. The supervisor I spoke with at Cigna said that the pricing from Tufts Health Plan is random. Too bad we weren’t on a recorded line.
Cigna cannot speak directly to Tufts Health Plan about pricing. When Cigna sends a query to Tufts Health Plan pointing out pricing problems or processing problems, the only response they have ever received from Tufts Health Plan has been “the claim processed correctly.” Tufts Health Plan has never admitted a mistake, has never acknowledged a difference in how they are processing identical claims for different dates of service, has never even acknowledged a difference in how they are processing the same claim when they process it a second or third time. The answer is $90.59. The answer is $138.54. The answer is correct, regardless of which answer it is.
Cigna claims they cannot audit the pricing from Tufts Health Plan, because they have no way to see any of the numbers themselves. They simply have to trust that it’s correct, and in turn assure us that it’s correct. Even when it clearly isn’t.
This is separate from how the pricing interacts with our deductible and our out-of-pocket maximum. That part happens after the pricing, as part of deciding how much we pay and how much Cigna pays.
Would you get away with this at your job? Provide an arbitrary answer, change the answer whenever you feel like it, and refuse to answer any questions about it?
Cigna claims that they offer this arrangement because Tufts Health Plan has a wider network in Massachusetts, and because Tufts Health Plan gets better pricing in Massachusetts. We haven’t personally run into any providers who are in-network for Tufts Health Plan and out-of-network for Cigna, and on the rare occasion that Cigna has been willing to look up their own pricing for a claim to compare it to the Tufts Health Plan pricing, the Cigna pricing has been comparable or cheaper. So why are they really doing this?
A patient goes to the doctor. The doctor has a list price, the doctor agrees to bill the patient’s insurance, the patient agrees to pay whatever portion insurance doesn’t pay, and the doctor (being in network) has a separate agreement with the insurance company to accept the negotiated price as payment in full.
In a normal scenario, the doctor’s list price (full billed amount listed on the chargemaster) is $300, but the negotiated price with the insurance company is $200. The insurance company pays somewhere between $0 and $200, the patient pays the rest to a total of $200, and that’s the end of it.
In a screwy scenario, the doctor’s list price is $300, but the negotiated price with the insurance company is $350. The insurance company pays somewhere between $0 and $350. What does the patient owe?
The doctor can seek payment from the insurance company, and presumably is entitled to collect up to $350 from the insurance company under the terms of the doctor’s contract with the insurance company. But what exactly entitles the doctor to seek more than $300 from the patient, if the insurance company has paid less than $300?
(In a sane world, the insurance company would never agree to pay more than the list price. We don’t live in that world.)
My feeling is that when I provide the doctor with my insurance information, I am allowing him to bill my insurance and keep whatever he collects from my insurance. But the fundamental debt is mine, and the insurance company is simply helping to cover that debt. If I can owe more than the list price simply because the insurance company has negotiated an even higher price, then my relationship with the insurance company is backwards and I’m helping to cover the insurance company’s debt.
I’ve seen this sort of too-cozy relationship with auto body shops and car insurance, where the body shop feels that the insurance company is the customer rather than the car’s owner being the customer.
Suppose that the fundamental debt is mine, and suppose that the doctor cannot seek more than $300 from me, but is allowed to keep $350 from the insurance company if the insurance company decides to pay the bill in full. What if I see the doctor twice with a list price of $300 each time, and the insurance company pays $350 for the first visit and only pays $100 for the second visit? Should the amounts be aggregated? If each visit is treated separately, then I owe $0 for the first visit and I owe $200 for the second visit. If the visits are aggregated, then I only owe $150.
You know what we need? Some sort of clear rules about how all this works. I’m surprised that I’m having so much trouble finding those rules. If we had insurance regulations, those would probably address this sort of question, wouldn’t they?
Summary
When Cigna refuses to pay for Early Intervention services, the taxpayers of Massachusetts get stuck with the bill. This could easily be costing Massachusetts $1 million to $2 million per year or more. We had an employer-provided health insurance plan through Cigna in 2013-2014. Our child received Early Intervention services. Despite our plan documents saying that Early Intervention services were covered, Cigna denied every single claim when it was first submitted. Our experience on more than 40 claims totaling over $8000 was that Cigna consistently lied about our plan coverage in an attempt to make Massachusetts pay instead of Cigna. After more than a year of appeals, we were able to correct our claims, but that only corrects the payments for one child out of the 36,000 who are in Early Intervention. Massachusetts should investigate how many times Cigna has pulled this scam, and stop it from continuing.
What is Early Intervention (EI)?
Early Intervention is a set of developmental services provided to children from birth to their third birthday. It includes evaluations, individual home visits by social workers and developmental specialists, and group services. Each EI agency that provides EI services in Massachusetts covers a specific town or region. You can find a lot of information about EI at http://www.mass.gov/eohhs/gov/departments/dph/programs/family-health/early-intervention/family-info/about-ei.html.
Who pays for Early Intervention in Massachusetts?
Early Intervention services are sometimes covered by health insurance. Massachusetts has a coverage mandate for EI services, but that mandate is not obligatory for self-insured plans. The Massachusetts Department of Public Health pays for any costs not covered by insurance, including co-payments and deductibles. The EI provider submits claims to health insurance when health insurance is available, and then any remaining amounts are submitted to the state for payment.
What happens when an insurer like Cigna wrongly refuses to pay for EI services?
The state gets stuck with the bill instead, while the insurer (or the employer in the case of a self-insured plan) saves money. The EI provider still gets paid, and the families still receive EI services, so the state is the only party that suffers a loss.
DPH makes EI providers report when services are not covered by a commercial plan, but that process assumes that the insurer is being truthful about whether EI services are covered. This assumption that an insurer will be truthful is a huge vulnerability which Cigna is able to take advantage of.
How much money could be involved?
The most expensive month we saw was $1207.01, while other months were typically $800 to $900. From our experience, this could easily mean costs on the order of $10,000 per year for one child. In Fiscal Year 2014, there were over 36,000 children enrolled and receiving EI services. Over 16,000 had commercial insurance. The state paid over $147,000,000 for EI services, which would be on the order of $7000 per year per child on average.
As of a few years ago Cigna covered over 10% of the people in Massachusetts with commercial insurance. That could translate into 1600 children covered by Cigna who are receiving EI services. At $7000 per year per child, if Cigna is wrongly denying even 10% to 20% of those services, that would be $1 million to $2 million per year.
How did Cigna treat Early Intervention claims for your child?
Cigna denied every single Early Intervention claim that was submitted for our child. There were over 40 EI claims over the course of a year, many covering more than one date of service, and Cigna denied every claim. Our Summary Plan Description said that Early Intervention services were covered. Whenever we called Cigna, we were told that Early Intervention services were not covered. The EI provider successfully appealed a few of these denials, but they eventually gave up and started to believe Cigna when Cigna wrongly said that EI services were not covered. After we placed many phone calls appealing these denials, persisting through repeated denials and incorrect statements from Cigna, Cigna eventually reprocessed and paid these claims.
The initial claims processing from Cigna was completely consistent: no EI claim was paid on the first submission.
Was this deliberate fraud on the part of Cigna?
When an insurer shows a pattern of denying every legitimate claim, lies about coverage whenever a customer questions the denials, ignores the statements in the Summary Plan Description, and knows that a third party will end up footing the bill instead, it certainly doesn’t look good.
Was the problem with Cigna or with Tufts?
Our self-insured plan is administered by Cigna, but the claims that Cigna receives within Massachusetts are sent on to Tufts Health Plan for processing. Cigna created the Summary Plan Descriptions, we only interacted with Cigna, and Cigna consistently refused to acknowledge that there was anything wrong with these claim denials, so it looks to me like a problem with Cigna.
(It is clear that the problem was not tied to the employer, who put together a perfectly good insurance plan and chose a major health insurance company to administer the plan.)
How would Massachusetts recover money from Cigna?
1. Identify which EI claims are being submitted to Cigna and are being denied on the basis of services not being covered by the plan. This information should be known by EI providers and by Cigna, and should be collected by DPH.
2. Total up those denied claims per child.
3. Start with the children with the largest total dollar amounts of denied claims in a year. Check the Summary Plan Description or other plan documents for each child’s plan to see which plans are supposed to cover EI services. It should rapidly become apparent how widespread this pattern is, and how much money the state stands to recover from Cigna.
Who should investigate?
The Massachusetts DPH is losing money because of Cigna. The Massachusetts Inspector General might like to save the state some money. The Massachusetts Attorney General might like to put a stop to insurance fraud that directly impacts the state’s budget.
How could state laws or regulations be changed to reduce this problem?
Whenever an insurer denies a claim for EI services, the insurer could be required to provide a copy of the actual plan documents (such as a Summary Plan Description) to DPH. DPH should check the actual plan documents for each child once per year to confirm that the denial is correct.
When an insurer wrongly denies EI claims on a repeated basis, there should be clear and significant penalties assessed. An insurer like Cigna apparently needs a financial incentive to avoid defrauding the state.
The law:
https://malegislature.gov/Laws/GeneralLaws/PartI/TitleXII/Chapter71/Section54B
DPH regulations:
http://www.mass.gov/eohhs/docs/dph/regs/105cmr210.pdf
State Dept of Education:
http://www.doe.mass.edu/cnp/allergy.pdf
2015 survey for schools about epi pen use:
https://www.surveymonkey.com/s/EpiPen2015
504 plan recommended as a mechanism for ensuring allergy safety in school:
http://www.mass.gov/eohhs/gov/departments/dph/programs/family-health/directions/chap-8/504-plan.html
(And by the way, Mass DPH issues an annual report on EpiPen use in schools which always concludes with recommending that students with allergies have a 504 plan.)
Some overall info about 504 plans from the Office for Civil Rights:
http://www2.ed.gov/about/offices/list/ocr/docs/hq5269.html
How anaphylaxis works on a cellular level:
http://luriechildrens-salubrity.tumblr.com/post/118705177170/the-science-of-anaphylaxis-an-allergic-storm
Non-negotiable points for an allergy plan:
http://foodallergyconsulting.com/top-3-non-negotiables-food-allergy-plans-2/
We have a Samsung French door refrigerator. We like it. Well, we like some things about it. It’s large, it keeps our food cold, and it turns out that we really like having the freezer on the bottom.
But it’s also a defective piece of shit, and we don’t like that side of it as much.
Nothing interesting. Flames don’t shoot out the doors when you open the fridge. It doesn’t wobble its way across the kitchen and start molesting the microwave. But the glides that let the freezer drawer open broke after a year. Samsung replaced the glides, and the replacement glides stick all the time, making it very difficult to open the freezer all the way. Samsung says it’s supposed to be that way, because who wants to open the freezer?
Oh, and the door and freezer gaskets aren’t really all that strong. And food along the back wall of the refrigerator compartment tends to freeze, so you can’t use the back couple of inches of the refrigerator, but that’s ok because the refrigerator is really deep so there’s a lot of room anyway.
But the truly annoying thing is when you go to close the left refrigerator door, the one that has the little divider flap that seals up the space between the left and right doors, and the divider flap doesn’t flip itself to the right position and your door bounces back open because the divider flap won’t let the fridge door close. Until you put everything down, hold the divider flap in the right place, and carefully close the door, because that’s convenient. Every. Time. You. Use. The. Door.
Why would that happen? Well, Samsung used a crappy little spring to manage the divider flap, and that spring lasts about 16 months before snapping into two pieces. And the plastic sleeve that it goes into also breaks apart after a bit over a year. Next week we’ll be on our third of each in less than four years. So you have to keep replacing these little pieces, and apologizing to your family and friends for your defective refrigerator until the parts arrive, and explaining that no, you really don’t recommend Samsung appliances, but you also don’t feel good about throwing out a $2000 refrigerator after just a few years, so you’re reluctantly living with it.
Samsung’s attitude is telling. A one-year warranty, because most of the refrigerator parts last at least a year. (Yay?) A one-time repair out of warranty, because that gets you in the habit of repairing your refrigerator instead of demanding a refund. And then an insistence that you start giving Samsung more and more money for repairs that don’t even hold up, with the excuse that they’ve already covered repairing their defective appliance out of warranty once, and how could you possibly expect them to keep repairing their defective appliance without bleeding you for more money? I mean, that would clearly be unreasonable, because an appliance company shouldn’t have to pay for five repairs in four years. With no acknowledgment of the fact that an appliance shouldn’t NEED five repairs in four years, and that if it does need five repairs in four years, that’s their fault and they should absolutely be on the hook for repairing it or replacing it.
Wondering where to legally dispose of sharps (needles, syringes) in Medford, MA? Since 2012, Massachusetts has not allowed used sharps in household trash, but the state did not set up any consistent plan. Some health care facilities might take them, or perhaps you can find a friendly pharmacy or doctor’s office.
Here’s the official answer: Sharps can be disposed of either at Medford City Hall outside the Board of Health Room 311 or at the police station next to the prescription drug take-back box.
Leaving your used needles on the sidewalk next to the playground is not recommended, though it is an improvement over leaving them in the playground itself. So if you’re one of the people in our neighborhood who has been doing that, now you know.
Problem solved, right?
*Opiate addiction is a serious problem. The Medford Police Department documented 39 non-fatal opiate overdoses between January 2014 and January 2015. Armstrong Ambulance’s first responders used Narcan on 94 patients in Medford in 2014. Apparently the police do documentation about as well as they do anything else. And they still aren’t bothering to carry Narcan themselves, nor is the fire department. If you need help, please seek help. If you seek help, I hope you get it. But if you keep leaving your used needles where toddlers can get to them, I hope someone kicks your fucking teeth in.
Prometheus Labs offers some rather expensive laboratory tests, most of which are only available from Prometheus. The blood is drawn anywhere, shipped to Prometheus in California, and the results are sent to the ordering physician.
The pricing is pretty arbitrary. The first time that Prometheus does a remicade trough level for a patient, they bill $2500. After the first time, it’s just $375. There’s absolutely no justification for this sort of price difference.
Prometheus is not in network for most insurance plans. It’s not clear if they are in network for any insurance plans. They do participate in multiplan, which can reduce the bill by 10% if your insurance plan has a deal with multiplan. Prometheus does bill insurance plans, and they file appeals on (some) larger bills, but they don’t generally count on insurance companies paying them.
Our insurance has denied Prometheus claims, saying at various times that they are not medically necessary, not preapproved, or out of network. The denials are arbitrary, and we’ve been able to appeal them to have them processed either as out of network, or even processed as in network based on the lack of an in network provider who can offer these tests. The appeals process is also arbitrary and can take months (the longest so far took close to 2 years). When we tried getting a prior authorization for a Prometheus test, the insurance company waited over 3 months to give a reply, and then denied the prior authorization. In the meantime, they had already approved the actual claim for the Prometheus test. Left hand, right hand, miles apart.
If your insurance does not pay, then Prometheus will offer to reduce the bill to $250, or possibly less if your income is low enough. This can be a great deal on the first remicade trough level if your insurance applies the $2500 (or $2250 with multiplan discount) to your deductible on a high deductible plan, but you only have to pay $250 at most. Even with a $375 bill reduced to $250, you can save a little bit on your deductible. The same logic applies if you’re likely to hit your out of pocket maximum for the year. It can get complicated with in network and out of network cross-accumulations, which are very dependent on your particular insurance plan. We now know ours much better than we used to.
After years of struggling to understand how to navigate all of this, we discovered that Prometheus has a deal with a few of the thousands of third party labs and hospitals that can draw the blood to have the third party do the billing. The third party pays Prometheus and bills your insurance. If the third party is in network, all of a sudden there’s no more arguments with the insurance plan (at least in our experience). And bizarrely, it can be much less expensive than the direct billing from Prometheus, even with the discounts that Prometheus offers for moderate income patients. For one recent test, the options were $270 from insurance to Prometheus, $250 from us to Prometheus, or $100 from us to the third party (with an unknown amount going to Prometheus out of that). Quest, that wondrous nationwide megalab agglomeration, can draw blood and ship it to Prometheus and bill the insurance plan for the test as Quest, but only from some regions of the country. Ours is not such a region.
Why does Prometheus charge $2500 or $375 for the same test at different times? Why does both a $2500 test and a $270 test get reduced to the same $250 for an individual paying the claim? Why does Prometheus accept $100 or less as full payment from a third party lab, while they demand far more from an individual even if the individual offers to pay in advance? And since their prices are completely arbitrary, why not let the patient request a higher bill to the insurance company if that will help the patient?
Depending on the details of your plan and where you are personally in your plan year, you might be better off paying a $100 in-network bill, or you might be better off paying $250 while having your in network or out of network deductible reduced by a higher amount. This isn’t a path towards rational or transparent pricing for health care. It’s not even a path towards giving patients an incentive to choose the lowest price.
The FDA made a big announcement in February, right before Valentine’s Day, that they had tested 100 different dark chocolate bars which supposedly do not contain milk, and found that many of them actually did contain milk. But the FDA refused to list the specific bars that tested positive or negative for milk.
I’m a little baffled by the FDA’s continued failure to release this information. So I’m trying a FOIA request: “The FDA recently tested dark chocolate bars for the presence of milk,
and announced a summary of the results:
http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm433555.htm.
I am requesting the specific results underlying the summary: which bars
were tested by the FDA (brand, flavor, and any other identifiers), and
the amounts of milk found in each bar tested.”
If I get any actual information by doing this, I’ll share it here.
Health insurance is all about limits. You can only see a chiropractor 20 times in a year. You can only pick up a 30-day supply of your prescribed medication. You can only see a specialist if you get a referral.
My question today is whether there should be any limits on the health insurance company? I’d like to cap the number of lies they can tell at a reasonable number, and require them to go through a medical review before telling more lies.
This morning’s example: Cigna denied a claim from March 3, 2015, because of a lack of precertification (prior authorization, prior auth, PA, precert, it’s important to keep shifting the terminology). But we had a precertification approved by Cigna last year, valid until April 14, 2015. When asked this morning, Cigna said that the precertification did not exist. Then Cigna said that the precertification had never existed. It took some forceful arguing before they were willing to admit that the precertification actually was on file exactly where it was supposed to be in their system, and that Cigna needed to approve the claim. But nowhere in there did the Cigna rep think there was any problem with her script or training requiring her to lie repeatedly, nor did she think that there was any good reason for me to be aggrieved about being lied to.
I think there’s a way to fix that. Require that all health insurance companies keep records of all communications with customers, including recordings of phone calls, along with all notes made by CSRs. Customers should have full access online, the same way that I can access claims information. (Right now, I theoretically have the right to get copies of those notes, but it requires notarized mailed paperwork, months of waiting, and an incomplete reply on disorganized printouts.) Then establish a Consumer Health Insurance Protection Bureau modeled on the Consumer Financial Protection Bureau, whose complaint system works quite smoothly for simple problems. Along with straightening out simple problems, the CHIPB could have a swear jar with a set penalty for each time the health insurance company lies to a customer in a recording or in their own notes. Maybe $20, with half going to the CHIPB budget and half being given to the customer? And a higher penalty for the health insurance company “losing” recordings or notes.
At the moment, Cigna doesn’t care whether they lie to a customer about a precertification, or about whether a procedure or medication is covered, or about whether a provider is in network, or even about what they themselves have said within the same conversation. Cigna loses nothing for lying, so over time they lie more and more. That needs to change.
If we ever shift to single-payer, we’re going to have a reintegration problem for health insurance company employees. We’ll have to train them not to lie, not to erase records and evade responsibility, not to see the customer and the provider as enemies. Because having thousands of Cigna reps working in Target without a lot of retraining is going to be hell on everyone. What, you want to buy socks? There’s going to be a waiting period for that, you can only buy 1 sock per week, we’ve never sold socks, the socks that your wallet covers are only available in a single store in New Hampshire, you have to prove that you tried stockings and those didn’t work, and the price for the socks will be randomly assigned 3 to 12 weeks after you’ve worn them.
