We are living in an era, in the U.S., when the insurance company often overrides your doctors’ decisions. Less often with traditional Medicare but more with commercial health insurance and Medicare Advantage plans, you may find that a test or procedure your physician ordered is refused payment by your insurer and you are stuck with a huge bill.

            A recent report by the Kaiser Family Foundation found that in 2020, 18% of in-network claims were denied by commercial insurers. Don’t passively accept this decision! The denial letter is just the start of the process, not the end.

            It has been shown that many of these denials are arbitrary and unjustified. A well-know example is the physician reviewer who admitted in court that he never even read the documentation but rubber-stamped nurse reviewers’ denials.

            The denial may be based on a wrong diagnosis code being submitted or a failure of the insurer to consider changing medical standards.

            While very few people challenge these denials, almost half the appeals succeed.

            What can you do?

            First, carefully read the denial letter to try to understand the reason coverage was denied. Yes, the prose is dense, but the insurer must explain its reason for denial.

            You may find that before they pay for C, they want you to try A and B first and you have already tried A and B without getting any benefit. You may find that the test or procedure is not considered appropriate for condition X and you have condition Y.

            If they have the facts correct and simply refuse payment, you will need to get the ordering doctor involved. They will have to write a letter explaining why they chose to do the test or procedure.

            Your first point of contact should be the insurance company’s customer service line. Be sure to get the name of the person with whom you speak. For simple mistakes, they may be able to reverse the denial, but don’t count on it.

            Your next step is to write a letter or an email requesting the denial be reversed and saying why. The process should be outlined in the denial letter. If not, it will be on the insurer’s website.

            If the response is to still deny the claim, persist. Request an appeal. Indicate in your request that you plan to file a complaint with your state’s consumer protection bureau if the claim is still denied (and do so!).

            Finally, outside help is available through the Patient Advocate Foundation and similar organizations.

            Illegitimi non carborundum! Don’t let the bastards grind you down!

            Edward Hoffer MD is Associate Professor of Medicine, part-time, at Harvard.

What Does The Doctor Say?

By Dr. Edward Hoffer

The Muppet character Count Von Count on Sesame Street must have been inspired by the federal government. Let me explain. The United States government is obsessed with numbers, just like the Count. There is the U.S. Census Bureau which is charged with counting every resident in the country, plus all manner of other data. With a country of 345,426,571 people at last count, Count Von Count would be in numbers heaven.

            When the Dracula-like Muppet finishes crunching those numbers, he can reckon with those of the National Vital Statistic System (NVSS), formerly known as U.S. Bureau of Vital Statistics (USBVS), which counts the number of births and deaths in the country. USBVS is part of the U.S. Department of Health and Human Services (HHS) which also includes the Centers for Disease Control and Prevention (CDC) which also counts how many people are sick. The states are represented in the federal government by the National Association for Public Health Statistics (NAPHSIS).

            Got all that?

            As you can see, the government is also obsessed with letters. There is also the National Aeronautical and Space Administration (NASA), the Environmental Protection Agency (EPA), the Federal Emergency Management Agency (FEMA), the Department of Energy (DOE), and the Department of Transportation (DOT). Not to mention (but I will) the Federal Aviation Administration (FAA), the Federal Bureau of Investigation (FBI), and everyone’s favorite, the Internal Revenue Service (IRS), and many, many more.

            All of these come under the Executive Office of the President of the United States (POTUS), who is under the control of FLOTUS (the First Lady of the United States).

            Often, sometimes inadvertently, these acronyms spell words, like DOT (Department of Transportation), DOE (Department of Energy) and, in Massachusetts, the office of Public Safety and Security (PSS). Oops, that’s not a word, it just sounds like one when said out loud.

            Even our town government has its share of letter salads. In fact, our distinguished Town Administrator, Mike Lorenco recently presented a seminar on municipal finance terminology for newly elected Finance Committee (FINCOM) members.

            Lorenco started by explaining that the DLS (state Division of Local Services), a division of the DOR (Massachusetts Department of Revenue) provides important information to the public and municipal leaders. He went on to says that PILOT (Payment in Lieu of Taxes) is an agreement that require entities that are not subject to pay taxes to…well, pay taxes.

            Any money left over after budgets are completed…the amount of taxes refunded to the taxpayers (just kidding) …is known as “Excess Capacity.” It could be called EXCAP for clarity. If you are a retired town employee your “post-employment benefits,” like health insurance, are called OPEB’s. (Where did the “O” come from?). And BAN is a Bond Anticipation Note. I think that means money the town needs to borrow if the FINCOM thinks there will be a shortfall. But I may be wrong.

            I believe using acronyms for other town board would go along way to clarify government to the populous. How about we call the Selectboard SELBO (pronounced like elbow. They could use a nudge once in a while). The Capitol Planning Committee (CAPLA) and the School Committee (SCHOCOM) sound very bureaucratic, as does PLABO for the Planning Board and RESFU for the Reserve Fund.

            I think these would be a great addition to the municipal vocabulary.

            Don’t you agree?

            Mattapoisett resident Dick Morgado is an artist and happily retired writer. His newspaper columns appeared for many years in daily newspapers around Boston.

Thoughts on…

By Dick Morgado

Local resident Anne Johnson’s voice was full of joyful lilt as she recently shared her immigration story with us. She stated several times how much coming to America in 1954 meant to the McEntee kids, twin brother Patrick, brother Brendan, and sister Bridget.

The family dreamed of coming to America, their mother’s country of birth. But let’s back up a moment on that point.

Johnson’s mother was named Mary Kearney. She was born in the US. She would immigrate to Northern Ireland where she met and married Patrick McEntee. The McEntees would live in Northern Ireland for a few years before Mary, her husband, and their four little children would head to the US and settled their clan.

That’s not where the trans-Atlantic journey ends. The siblings would travel back to the motherland many more times over the succeeding decades.

Johnson shared how thrilled they all were to be coming to the US and all the opportunities the family looked forward to. There was no homesickness or trepidation on the part of the little ones. She did allude to the economic difficulties gripping the whole of Ireland during the post-WWII years as a driver for the move across the Atlantic – as well as the brewing tensions that would come to be The Troubles

We asked Johnson if there were any strong first impressions remaining with her today, “Cornflakes!” She said they had been growing up on a diet of porridge, eggs, and “rashers,” (aka bacon), and that the less soggy breakfast mainstay of the US made for a welcome change.

Transitioning to a new school in a new country didn’t present too many difficulties for the wee babaí. “We had thick Irish brogues. My brother and I decided we needed to get rid of that,” Johnson said with a tiny chuckle.” She said they did not experience bullying or similar difficulties and that their neighborhood was home to people from many different places, “We were all facing the same challenges.”

Johnson recalled their enrollment in a Polish Catholic School. There had not been enough time to enroll her children in an English school so the mother did the best she could to give them an education. The following year found the McEntees enrolled in an English-speaking Catholic school.

One memory is still vivid in Johnson’s memory bank – seeing the Statue of Liberty for the first time.

Another memory crept in, how hot the country felt to the new commers, and experiencing a hurricane, something unknown in Ireland. Much later on, Johnson would be introduced to Mattapoisett by family member Ellen Flynn, a well-known member of the Mattapoisett Land Trust and other organizations. Johnson and her husband put down their roots in 1974. She can confidently call herself a townie!

Three of the four siblings recently took another trip to the old country, but at least for Johnson, that is the last. Confessing that the family is aging beyond a point where travel is easy, she was clear that they had a fine visit, even going to tourist areas. She noted how their Belfast home has changed but that the countryside was and is, “…beautiful and the people are lovely and welcoming.” Of course, going on the journey was a copy of The Wander.

By Marilou Newell