The BCBSM Stone Wall

A law firm that assists clients with public benefits applications frequently runs into boneheaded bureaucrats who consider it their mission to make it as difficult as possible for anyone outside the organization to receive the services they are due. Usually, a supervisor or a representative at a different office or branch can be found who will be more cooperative. Seldom does the law firm find itself trying to transact business with an entire organization of obstinate, discourteous boneheads. Blue Cross Blue Shield of Michigan (BCBSM) is such an organization.

Trying to procure a paper premium statement can take weeks if the insured person is not able to call BCBSM, hang on the line for 30 minutes or more, and explain what is wanted. When the insured is represented by an agent under a durable power of attorney, a retained attorney, or the spouse who pays the premiums, getting a paper premium statement usually involves a lengthy telephone campaign to get permission to mail or fax the power of attorney. Then it is necessary to wait for days for some sort of response.

Bear in mind that the information sought is not confidential medical records covered by HIPAA. It is just a paper premium statement that could be sent to the insured in the normal course of business.

Recently, a client told us that she had been trying for weeks to get a premium statement from BCBSM. She was told that a company release of information would be sent to her. It never came.

Because of past experience, I directed my request for a premium statement to Jeffrey Rumley, General Counsel of BCBSM. I attached the power of attorney signed by the insured appointing his agent. I also attached the release of information and appointment of representative giving me the right to request information and represent the insured. That document was signed by the agent. Nearly every bank, insurance company, real estate agent, brokerage firm, and government agency with which my office deals would honor a request backed up with a power of attorney and release of information. Not BCBSM!

Two days after emailing Mr. Rumley, my office received a call from a BCBSM representative. She stated that BCBSM does not recognize any power of attorney drawn up by an attorney — which is asinine. She stated that to get any information, the insured, who is in a nursing home and incapacitated, must sign a request on BCBSM’s form.

Furthermore, she stated that BCBSM would not fax the form, it would have to be mailed. There was no explanation of why they could not fax the form to my office, despite the fact that it would have no personal information of the insured – or anyone else – on it.

After a second emailed letter to Mr. Rumley, an assistant general counsel finally provided a link to procure the form for an agent under a power of attorney and a dizzying array of similar forms. The forms are, and have been, available to anyone with online access. Why the BCBSM representative was so coy is a mystery.

For BCBSM, which recently inflicted double-digit premium increases on its customers, to make it so difficult for people in nursing homes to get information needed to apply for Medicaid is appalling. There are thousands of BCBSM insureds receiving long-term care. There is no excuse for making it an excruciating ordeal to get premium verification for Department of Health and Human Services. Instead of erecting a bureaucratic brick wall, it should be possible to request that verification be sent to the Medicaid agency with a telephone call:

BCBSM: How may I help you?

Caller: I am applying for Medicaid for my mother, Suzanne Sugerbaker, and I would like insurance coverage and premium verification to give the worker.

BCBSM: We can send that directly to the Medicaid agency if you give me Suzanne’s Blue Cross member number and the case number assigned by Medicaid or her Social Security Number.

Caller: Suzanne’s Blue Cross member number is IDK313250075. Her Medicaid number is 8182850205.

BCBSM: Thanks, I’m sending the information right now.

This should not be difficult. If Google knows that I went to Wendy’s at noon and ate a Double-Double Baconater, then went to Walgreen’s at 2:24 p.m. and bought Nexium, how hard could it be for an IT juggernaut like BCBSM to verify a member’s premium and coverage to a government agency through a data link? I’ll bet that BCBSM already keeps track of how many Baconaters I eat.

John B. Payne, Attorney
Garrison LawHouse, PC
Dearborn, Michigan 313.563.4900
Pittsburgh, Pennsylvania 800.220.7200
law-business.com

©2017 John B. Payne, Attorney

Advertisement

Repealing the Affordable Care Act

Without spin or editorializing on the issue, here are some facts from The Center for Medicare Advocacy, medicareadvocacy.org, about the program Congress plans to repeal:

• The uninsured percentage of Americans under 65 is the currently the lowest in decades. Beginning in 2014, the rate dropped from 16.6% to 10.5%.
• As of March 31, 2016, 11.1 million people have coverage through the ACA Marketplace.
• As of 2015, 11 million people in 31 states and the District of Columbia had coverage through Medicaid expansion under ACA, out of a total of 81 million on Medicaid.
• There are 19 states that did not expand Medicaid: Alabama, Florida, Georgia, Kansas, Idaho, Maine, Mississippi, Missouri, Nebraska, North Carolina, Oklahoma, South Carolina, South Dakota, Texas, Tennessee, Utah, Virginia, Wisconsin and Wyoming.
• However, the ACA resulted in 16,748,000 people becoming eligible for Medicaid as of September 2016.

Congress says it will replace the ACA with something better. Dare we hope?

John B. Payne, Attorney
Garrison LawHouse, PC
Dearborn, Michigan 313.563.4900
Pittsburgh, Pennsylvania 800.220.7200
law-business.com

©2017 John B. Payne, Attorney

The Prescription You Do Not Need

Among the clues that one is no longer young can be proliferation of prescription drugs in the medicine cabinet. In this age of miracle drugs you do not even have to be “older” to be taking a regimen of four, five, or more prescriptions, daily. Aggravating this tendency for Americans to take more and more prescriptions is the fact that there is no central registry of an individual’s prescriptions, so doctors are often unaware of all the drugs a patient is taking.

Once, while volunteering as a drug crisis counselor in the ‘70s, I was called to the home of a factory worker. This was unusual because most of our calls were for overdoses of psychedelics or “downers” by students and those who tuned in, turned on and dropped out.

The man was sitting at his dining room table staring out at his back yard, catatonic. He had been seeing a large number of psychiatrists, who all gave him prescriptions for strong mood-altering drugs. His wife showed us a large toiletry bag holding dozens of psychotropic prescriptions. It was no wonder he was in the o-zone.

In 40 years there has been little progress toward protecting patients from conflicting treatment plans from different doctors or unnecessary prescriptions by scrip mills. Pill freaks can still go from doctor to doctor collecting drug prescriptions at every stop. Now they are even armed with all the brand names of the pills they probably do not need because television is polluted with Big Pharma ads, as documented today by Bloom County.

I recently learned of another aggravating factor in the drug tsunami pouring over our country – drug “protocols.” A client who takes two prescription drugs recently picked up her prescriptions and found a third in the bag, a generic for Prilosec. Surprised, she looked it up on drugs.com and learned that it is a proton pump inhibitor (PPI). She told me, “I did not know that my proton pump needed inhibition. I always thought my lack of inhibition was part of my charm.”

Reading further, she learned that PPIs are used to treat heartburn and acid reflux. She had never had a problem with her GI tract and eats highly spiced, exotic foods with gustoand no ill effects.

Prilosec was recently found to be associated with an increased risk of dementia. In addition to the dementia risk, there was a respectable catalog of dire side-effects, such as diarrhea, muscle pain or spasms, heart-rate abnormalities, and seizures. Finally, since PPIs suppress production of stomach acid, the body tries to compensate for the increased pH in the gastro-intestinal tract after a period of PPI use by producing more stomach acid. This requires ever-higher doses or a more powerful PPI.

Now both curious and alarmed, she called the office of the doctor who prescribed the PPI to ask why. The nurse checked with the doctor, who told her he prescribed the PPI because it is listed in a drug “protocol” for her condition, which had nothing to do with the GI tract. In response to her expression of concern that she was being prescribed medication for symptoms she did not have, the nurse assured her that “everyone” takes PPIs. The nurse, herself, takes Prilosec, but will be graduating soon to a more powerful medication for acid reflux because Prilosec is losing its effectiveness for her (Remember about the body’s response to prolonged use of PPIs?).

Writing a prescription based on a drug “protocol” is like prescribing for a real patient from a hypothetical medical record. This raises concerns on many fronts.

First, if the patient does not have the condition the drug is intended to treat, the doctor is introducing unnecessary interactions with other drugs. Even if the doctor knows all the prescriptions the patient is using, he or she is not with the patient on a daily basis and will not know about over-the-counter drugs and supplements the patient may be consuming or lifestyle circumstances and diet that may affect how the drug is tolerated. A real patient is likely to differ in important ways from the hypothetical patient on which the protocol is based.

Secondly, prescribing from a protocol will lead to an upward spiral in the number of prescriptions doctors write. A drug protocol created by, or with the connivance of, the pharmaceutical industry will include every possible application for every drug, but will not catalog contraindicated products. As a consequence, the list of suggested pharmaceuticals for a given diagnosis will expand over time, but never contract.

Finally, many patients will take whatever prescriptions a doctor gives them. They may not realize that a prescription is treatment for symptoms or conditions they do not have. An unnecessary drug may become a regular part of the patient’s drug regime and the side effects of that unnecessary drug may require still more prescriptions to treat those side effects. Patients in assisted living facilities and nursing homes are especially prone to take pills they do not need. They are handed their medication and take it without question.

One resident in an assisted-living facility was taking over $500.00 per month in medication and was almost totally unresponsive. When the family had a money problem and couldn’t pay for the prescriptions, they stopped giving them to her. She soon perked up and started asking about her grandchildren. She had been chemically restrained to make her more tractable.

Our consumption of pharmaceutical products is out of hand. Automatic inclusion of additional substances based on a hypothetical model of a patient’s diagnosis would be one more aggravating factor. Physicians need to prescribe treatments based solely on analysis of the specific patient’s symptoms and conditions and patients need to be more inquisitive about the prescriptions they are being given. Further, any patient who is taking more than three prescriptions should have a periodic review by an independent pharmacist or different doctor to analyze the drug interactions going on.

John B. Payne, Attorney
Garrison LawHouse, PC
Dearborn, Michigan 313.563.4900
Pittsburgh, Pennsylvania 800.220.7200
law-business.com

©2016 John B. Payne, Attorney

Give the ACA a Chance

It is incredible that more than half the U.S. population are against the Affordable Care Act, especially when one third of the country is uninsured or underinsured.  People can be so gullible!  I pointed this out in Suck a Vile Vial.  Pour enough money into advertising and you can sell a two-ounce bottle of caffeinated slime for more than the cost of a gallon of milk.

Before the ACA was passed, I said to a client that the country needed a universal health-care plan.  He had been watching Fox News and listening to talk radio, because he became irate and said, “That would be socialized medicine.  It would be awful.  How could you suggest such a terrible thing.”  I responded, “Gary, you are 42 years old; you are unemployed, living with your father.  You have no health insurance and you cannot get Medicaid because you are not disabled.  How much worse would socialized medicine be for you?”  He was one of the 47 million uninsured, but if he had not died at age 45, he would now be telling his representative to vote to defund “Obamacare.”

Why do so many people want to go back to 2009?  The ACA may not be perfect, but it has to be better than the chaotic hodge-podge of insurance plans, Medicaid, hospital charity care, and unpaid emergency-room visits misnamed a “health-care system” that has plagued us since doctors made house calls driving Model Ts.  Sen. Ted Kennedy and Pres. Richard Nixon (yes, that Richard Nixon, who ended the war in Viet Nam) tried to enact mandatory health insurance for employers and state-run health coverage available to all.  That fizzled and various administrations since Nixon have tried to effect universal health-care coverage in one form or another.  What is the TEA Party plan?  Forty more years of a law-of-the-jungle health care mercantilism.

The ACA may not be perfect, but it is a step in the right direction.  Let’s take it for a test drive and see what the problems are.  Once we see how the program performs, we can decide what reforms are needed.  Dumping the ACA at this point would not set us back four years.  It would set us back 40.

 

John B. Payne, Attorney
Garrison LawHouse, PC
Dearborn, Michigan 313.563.4900
Pittsburgh, Pennsylvania 800.220.7200
law-business.com

 

©2013 John B. Payne, Attorney

 

 

Obamacare Individual Mandate Tax Compliance Form Hoax

A client told me today that his wife received an “Obamacare Individual Mandate Tax Compliance Form” that the IRS is now requiring. I told him that I found that hard to believe and asked him to fax it to me.

When I received the form pictured here, obamacare hoax I found that it was a hoax perpetrated by anti-health-care activists to incite opposition to the Affordable Care Act. If you look carefully at the bottom of the first page and the upper right corner of the second page, it states that this is not a real IRS form.

The perpetrators of this scam clearly find the facts insufficiently persuasive in supporting their position. Since the facts of the Affordable Care Act do not support repeal, they find it necessary to resort to mendacious stunts intended to fool the unsuspecting.

 

John B. Payne, Attorney
Garrison LawHouse, PC
Dearborn, Michigan 313.563.4900
Pittsburgh, Pennsylvania 800.220.7200
law-business.com

 

©2013 John B. Payne, Attorney

 

 

Affordable Care Act Mandate

Affordable Care Act Mandate

I subscribe to several listservs where there are conservative and TEA Party members.  The moaning and wailing over the Affordable Care Act individual mandate can be deafening.  It might be helpful to review how the individual mandate will really work.  This flowchart from the Henry J. Kaiser Family Foundation explains who and under what conditions a person might be subject to a penalty for not buying health insurance.

 

John B. Payne, Attorney
Garrison LawHouse, PC
Dearborn, Michigan 313.563.4900
Pittsburgh, Pennsylvania 800.220.7200
law-business.com

 

©2012 John B. Payne, Attorney

 

 

Supreme Court Media Whore

The Supreme Court does not allow cameras in the courtroom, but Chief Justice John Roberts is his own brand of media whore. He could have announced when the Patient Protection and Affordable Care Act decision would be handed down – many were expecting it today – but he wants to build suspense.

He is playing it the way television contest shows do it:

“We are down to Stymie and Fermi. Who will be the next American Idle? Stymie, you sang ‘Auld Lang Syne’ and ‘Happy Birthday.’ You danced the tarantala and the stumba. Fermi, you played ‘Flight of the Bumblebee’ on the Sousaphone.  You sang a bar of soap and rolled your eyes in opposite directions.  Our panel of judges has voted. America has voted. Our shaman has cast sheep’s knuckle bones and read chickens’ entrails. Stymie and Fermi, you are going to find out who won after these commercials.”

As if the PPACA decision needed more drama, Roberts has to drag the suspense out until tomorrow – or Wednesday – or Thursday. Come on, Johnny, drop the freaking bomb! The decision went to the printers weeks ago. Do you really have to be such a drama queen? Just give us the answer.

 

John B. Payne, Attorney
Garrison LawHouse, PC
Dearborn, Michigan 313.563.4900
Pittsburgh, Pennsylvania 800.220.7200
law-business.com

 

©2012 John B. Payne, Attorney

 

 

The Weight of the Nation

“The Weight of the Nation” is a four-part documentary on the national obesity epidemic that starts May 14, 2012 on HBO. In a May 10, 2012 video editorial, “The Tax Code Diet: The Institute for Medicine gets political on obesity,” Dan Henninger and Joe Rago, of the The Wall Street Journal, mock the documentary and the Institute of Medicine report on which it is based. WSJ Article. Their neo-Con “all government is evil” attitude should be seen as an unqualified endorsement of companies that push unhealthy eating habits to maximize profits with no regard for the health of their consumers.

Henninger and Rago, neither of whom are obese, do not deny that the nation has a problem. However, they ridicule the idea that the government might have a role in encouraging healthy eating. They claim that what one eats is a matter of individual choice and that the government should not attempt to regulate food packaging and advertising. They further argue that unhealthy products like carbonated soft drinks loaded with high-fructose corn syrup and caffeine should not be taxed to subsidize anti-obesity and healthy diet programs and other health costs attributable to those products.

Do the neo-Cons oppose food-safety inspections and regulation to protect us from pathogens like salmonella or mad-cow disease? Some social Darwinists would place all responsibility for food safety on processors and vendors. They would say, “Let the market sort out which manufacturers poison us and should go out of business, but even most neo-Cons would agree that we rely on the government to enforce food safety rules. When we buy beef or carrots at Piggly Wiggly we have confidence that the products are not drenched in E. coli because of government oversight.

Our food supply may be free of disease-causing pathogens, but what about high-fructose corn syrup, salt, and aspartame? What about the absurd mounds of fat, sugar, cheap meat, carbohydrates, and salt that Applebees, Burger King, Cheesecake Factory and other restaurants call “meals.” People tend to be gullible and when the restaurant calls something a “meal,” many customers will assume that what they will be served is a reasonable portion for one person to eat at one sitting. The restaurant is playing on customer’s credulity when it serves an “appetizer” with 1,500 calories or delivers a mass of food that exceeds 2,300 calories and calls it a meal. At the very least, calorie counts should be displayed on the menu or bill of fare.

In the supermarket, trusting consumers are fooled by advertising and packaging into thinking that candy is a healthy breakfast and cookies are nutritious snacks. The frozen-food aisle is crammed with pre-prepared entrees labeled “heart-healthy” or “lean” that barely qualify as “food.” Judging by the ingredient lists, which are often barely legible, a product might be lasagna or animal shampoo. Few shoppers have the time or the ability to really decipher what they are buying. They do not realize that “organic” and “natural” and “fresh” and “heart-healthy” are just advertising gimmicks that have no meaning. Shoppers assume that the government keeps food processors, distributors and retailers honest. That is far from the case, with some reasonable reforms shoppers could have the protection they deserve.

Watch “The Weight of the Nation” with an open mind. There is a crisis of obesity in the United States and we must curb our eating – particularly with regard to children. By allowing our children to overeat we are condemning them to a lifetime of obesity and all of the health problems caused by excess weight. We as a nation must address the problem and the government has an important role to play.

 

John B. Payne, Attorney
Garrison LawHouse, PC
Dearborn, Michigan 313.563.4900
Pittsburgh, Pennsylvania 800.220.7200
law-business.com

 

©2012 John B. Payne, Attorney

 

 

Republican Hypocrisy over Shooting of Rep. Gabrielle Giffords

The shooting of Democratic Rep. Gabrielle Giffords is a sad, but predictable, result of the type of vitriolic campaigning used by TEA Partiers and other right-wingnuts. When leaders accuse their opponents of being traitors and of desecrating the constitution, zealot supporters will interpret that as a green light for violence. There is only one way to interpret Sarah Palin’s use of rifle-scope crosshairs to indicate targeted Democrats on her campaign map: “Take ‘em out, Boys!” The Republican leadership set the stage for violence and has no legitimate claim to be anything but satisfied by the result.

Sarah Palin, John Boehner, John McCain, and other Republican leaders expressed “horror” over the shootings. I do not for a minute believe that they were anything but gleeful. They should keep their damned mouths shut.

I remember President Reagan claiming that he was “appalled” at the Sabra and Shatila massacres in 1982. His expression was as hypocritical as Palin’s, Boehner’s and McCain’s. Those massacres were carried out by Reagan’s ally, Ariel Sharon. Neither Reagan nor his administration lifted a finger to halt the massacres, punish the perpetrators, or assist the survivors.

There is no excuse for this kind of blatant duplicity. Right-wingers accuse anyone to the left of Sean Hannity of being a traitor and a Commie who is a danger to America. They claim that President Obama is a closet Muslim who was not born on U.S. soil and moan that the health reform act will destroy the country. Since we who are in favor of health care for all are evil people who are trying to wreck the country, is it any wonder that dedicated disciples of Palin and Boehner would decide that assassinating us is doing God’s work?

The TEA Party and Republican leadership should at least have the integrity to express their honest feelings about the shootings in Tucson. They are pleased and owe it to the country to admit it.

 

John B. Payne, Attorney
Garrison LawHouse, PC
Dearborn, Michigan 313.563.4900
Pittsburgh, Pennsylvania 800.220.7200
law-business.com

 

©2011 John B. Payne, Attorney

 

 

Afford It? We Must!

It is incredible that TEA Partiers and others against universal health care for Americans should claim that we cannot “afford” it. No responsible individual or family would fail to purchase health insurance unless so financially pressed that it came down to a choice between paying for health insurance and paying rent. Health care, like food and shelter, is a necessity for individuals and families and should be a necessity for the government. Everyone needs access to medical care–particularly children. The government cannot budget for defense and transportation and education and other government responsibilities and then say, “Whoops; no money for health care!” President Obama has finally accomplished meaningful health care reform and should be praised, not insulted.

Neo-Cons derogatorily refer to the health care reform act as “Obamacare.” If I were the President I would be proud to have my name associated with the most significant improvement in the nation’s health care system since Medicaid was enacted in 1965. The Patient Protection and Affordable Care Act of 2010 is not perfect, but calls to repeal it are the bleatings of vicious negativists. We cannot call ourselves a civilized society while more than a third of our citizens lack access to health care.

I was talking to a client a couple of years ago. I told him that we need a program of universal health care. He said, “No, that’s socialized medicine. That would be awful.”

“Gary,” I told him, “You are 42 years old, out of work and living with your parents. You have no health insurance. How much worse would socialized medicine be for you?”

Too many people like Gary are swayed by neo-Con and TEA Party rhetoric. We cannot ignore the needs of the uninsured any longer. The health care reform act is a step in the right direction. Neo-Cons and TEA Partiers who say they have a better plan are lying. They just want to leave the uninsured as they are. They have insurance and they have no concern for anyone else’s needs. The United States can afford to ensure that everyone has an affordable health plan. Anything less is uncivilized and ultimately more costly because ailments and injuries that are not treated become more serious and expensive to treat. Without insurance, patients end up visiting the emergency room, the least cost-effective venue to seek medical attention.

 

John B. Payne, Attorney
Garrison LawHouse, PC
Dearborn, Michigan 313.563.4900
Pittsburgh, Pennsylvania 800.220.7200
law-business.com

 

©2010 John B. Payne, Attorney