December 3 Meeting with Healthcare Trust Committee Chairman and our Union benefits advisor

Three days prior to my first RF ablation procedure on my back the Chairman for our Health care Trust Committee asked me to meet with he and our union benefits advisor, Dimartino and Associates.  The point of the meeting was to convince me that I had no need to appeal their decision not let me out of our union provided health care.  Further, it was to sell me on how, by having both Regence and my military retiree health care coverage with Tricare, I would be well taken care of.  They gave me the impression that it would be at least as cost beneficial as only having Tricare, with the further incentive that I would get some services with Regence that would not be provided if I only had Tricare (massage therapy).   Finally they told me that despite my best desires, Federal law under the Department of Labor (ERISA) prevented me from even being allowed to leave.   I was finally told that I would save the Union 10,000 dollars by not going through the appeal process.

I hesitantly agreed to drop my appeal and told them I would take them at their word that they would aggressively assist me in getting my health care issues resolved.  Along with taking care of my unpaid pain management bills, they told me they would work hard to get the money back that I should not have had to pay in both 2009 and 2010.  That sounded like a good thing, so I was skeptical but on board.

It has been now over 10 weeks and from my perspective NOTHING has been done.  I just got a bill from my pain management doctor for roughly 7900 dollars.  Based on my extensive conversations with both Regence and Tricare no efforts have been made to resubmit claims to regain the funds that I should not have had to pay in the last two years.  No progress has been made in having Regence pay for my medical treatment.  According to both Regence and Tricare no bills have been reprocessed; and all pain management bills have repeatedly been denied payment by Regence.   Lots of promises were made, but no progress has been made.  I was contacted by a Union member who told me he was under the impression that I had a special person at Regence personally handling my case.  Hmm, that person is not talking to those that process or reprocess the bills.  Further, none of my healthcare providers have been contacted to direct them to submit my health care bills to my secondary insurance, as I was promised in our meeting would be done.  A bunch of empty promises and I'm left holding the bills.

So I'm back to square one.   No progress.

So here is my new plan of attack:

-I've written the Chairman of the Senate Veterans Affairs Committee, and one of our U.S. Senators, Patty Murray.  I've spelled out to her the issues, my actions, and the promises made to assist me.

-I've submitted paperwork to reopen my workers comp case. If my case is opened than workers comp will not pay a penny, since my procedures were done prior to their period in which they retroactively pay.  The sole reason I'm jumping through this bureaucratic hoop is to appease Regence in that they have told me that if I were to attempt to reopen my claim and be denied twice they "might consider" paying the costs.

-I'm preparing a letter to the local media to spell out the issues I'm having with my healthcare, and the sheer lunacy of having such medical bills when I have two very viable healthcare insurance plans.

-I've contacted a injury attorney and will meet with him to discuss any options in regards to solving this issue through the Court system.  Obviously I'll discuss being reimbursed for my time, hassles and financial expenditures.


Well there you go.  Nice.
Attached is my letter to Dimartino and Associates to get in writing some form of commitment to the promises they made to me in our meeting.  Along with my letter is the letter I received from Dimartino, spelling out what they were either in the process of doing, or what they would pursue.  They asked that I be patient.  I think ten weeks is patient enough.  I think that when I get presented medical  bills for nearly 10,000 dollars and am being refused treatment because I have no health insurance than I've been plenty patient.  

My letter to Dimartino, after our meeting. 

From: John Bowen
[john@johnandbethbowen.net]

Sent: Friday, December 03, 2010 10:30 PM
To: xxxxxxx@dimarinc.com

Cc: O'Mahony, Timothy

Subject: Medical bill information

Xxxxxxxx,

Thank you for your time and effort today. I apologize if I came across either argumentative or belligerent. For obvious reasons, the entire issue of civilian health care insurance has
been a huge burden on me; financially, emotionally, mentally and in regards to
the many countless hours I’ve spent trying to ensure I receive proper benefit
coverage.   Given that for the most part those efforts on my part
have been ineffective and futile, it is extremely difficult for me to easily
accept your solution that, from my perspective, will require another huge
undertaking of my time to ensure things run as they should in the future;
without any further complications.   Hopefully I’ll be pleasantly surprised. 

You also asked for a list of my providers.  The attached spreadsheet is about as good as it gets in that
regard.  The spreadsheet indicates all the providers that my family has
used over roughly the last fifteen months, to include their phone numbers,
names of billing personnel, and my account numbers.   Some of the
entries may be providers that I paid for bills dating back to 2008.
Please note that I have paid out over 5000 dollars in payments over the last
fourteen months. 

Based on my understanding of what we spoke about today, I’d like to confirm that you’ll do the following to assist me:

-contact my providers, as listed in the attached spreadsheet and inform them that I have
Regence as my primary, Tricare as my secondary, and  that they are not to
bill me when Tricare pays less than the remaining balance after payment by
Regence.  In regards to my family, that obviously is not necessary; given
that Tricare is their primary provider.

-contact my providers that in the past have failed to process my secondary insurance
claims, having not forwarded it on to Tricare.

-contact Tricare and determine which payments were not properly processed in that they
should have been sent to Tricare as secondary.

-contact any providers that I have paid, based on their billing me for a remaining
balance, due to Tricare not processing any secondary claims. 

-Represent me in getting me reimbursed for those claims that have been paid by me which
should have rather been written off once they received notification that
Tricare either had paid their portion, or Tricare stated that no payment was
due to the provider, based on a different procedure payment schedule.

-coordinate with Regence to ensure they pay all of my pain management bills, which they state
they are not responsible for, given that it is a result of a work related, but
closed, injury.   Some of these bills have been either double paid or
singularly paid by Tricare, as you know. 

-Contact my pain management clinic and reassure them they are going to be paid.
They have been very patient through all of this over the last six months, as
Regence and workers comp both claim no responsibility for either my meds or my
treatment.  My pain clinic is going to go nuts when they find out that the
payments they have received are now being rescinded. 

You have my permission to query both Regence and Tricare for any information
that is not sufficient based on this spreadsheet.

I’m still
waiting on Tim to send me the documentation in regards to not being allowed to
opt out of the Union provided health care.  I’ll notify Benefits Solutions
that I do not desire a hearing upon  receipt of the citation or reference
to the Federal law prohibiting my ability to opt out of coverage provided by
the Union.   

Please also provide to me the rule, regulation or requirement that states a provider is to
write off the cost of treatment that Tricare does not cover.  I’m looking
for the reference you stated that indicates that my providers are not to bill
me, except for the amount remaining for my Tricare deductible.   I’d
like this reference so I can give it to the providers when they query or bill
me for the remaining amount not covered by Tricare. 

I can see from an administrative perspective this will get very confusing, given that most providers expect their copay up front; which will be based on the Regence copay amount, but I’ll
be only required to pay the Tricare copay amount.  Based on my
understanding of what you have told me; that would mean every time I see a
provider they will have to issue me a refund for the difference in the copay
amounts for Regence and Tricare. 

As you stated, I’m cautiously optimistic that you’ll be able to both ensure my future payments are properly processed and that you’ll be able to ensure that the providers in the future
will not continue to bill when Tricare states they are not liable for any
further payment.  I am hopeful but quite skeptical that you’ll be able to
recoup the 5000 dollars I’ve spent on medical bills over the last year. 
I applaud your ambition and energy to assist me, but have become increasingly
 cynical of the entire healthcare insurance industry, based on the
multiple and significant headaches my family has endured over the last ten
years in dealing with civilian healthcare. 

Sincerely,

John A. Bowen


Dimartino's Response to my Letter:

John,

Thank you for your patience as I put into motion the items we discussed
last Friday, December 3, 2010.  You captured the discussion well in your
message.

Since that discussion, here’s is where we are with my take-aways:

1. Correction of Eligibility:  I have confirmed with Regence that my contact has
        already begun the reprocessing efforts with TriCare.  The first step
        in this process is to correct TriCare’s system (recall that your, John’s,
        eligibility record at TriCare incorrectly noted you did not have
        primary coverage with Regence in 2010.  Once this correction has been
        made, the actual reprocessing of claims can begin.  My Regence
        resource will be confirming today if this correction has been done.
        As of this message, there has been confirmation.
2. 2010 Reprocessing:  As noted above, once the eligibility record has been
        corrected for 2010, TriCare and Regence will coordinate to ensure 2010
        claims are processed with Regence as primary, TriCare as secondary.
        As we discussed, this process may take several weeks to months to
        complete.  The good news is Regence will bird-dog the process on your
        behalf.
3. 2009 Reprocessing:
        Regence will also be coordinating the reprocessing effort for the 2009
        claims for you, John, and your family who in the year had double
        coverage.  There is some challenge with the rules around timely filing.
        TriCare indicates they may have shorter time frames regarding timely
        filing that other plans because of the nature of their business.
        Regence has committed to exploring every claim’s chance of reprocessing
        within those time frames.
4. Coordination with Providers:  My Regence resource confirmed today that she will
        contact all your providers to ensure they have the double coverage
        information and the correct order noted in their billing offices.
5. Your Back Surgery on Monday December 6, 2010:  I have contacted the Subrogation Department to discuss the merits of what they have asked you to do regarding the WC
        claim.  I received some hopeful information, but have not learned
        anything definitive as of the writing of this message.  The situation
        has been escalated to leadership in the Subro department and I am awaiting
        the results.  I’m sure you an appreciate that if the outcome is
        different than the letters you received on November 18, their department
        has to do some extensive research into what happened in order to over turn
        it.  This may take a few days.  Having said this, I am hopeful.  Stay tuned for more on that.
   

As a closing comment regarding all this activity, I want to assure
you that I am pursuing all avenues we discussed last Friday.  In fact, all
the activity was locked and loaded awaiting your agreement on that
Friday.  At this point, we are in the midst of beginning all these
processing on your behalf and it will take some time to fully research and
ultimately execute the action plan to correct the past as well as on-going
situations.  We do appreciate your patience and willingness to entrust
this very important matter to us!

We will continue to keep you posted on any progress made,
particularly regarding the services you received on December 6.

Thank you.

DiMartino Associates

1301 fifth avenue, suite
3701 | seattle, wa  98101 | ph: 206.623.2430 | fx:
206.812.7538