AP_insulin

A patient holds a vial of insulin during a news conference outside the Olde Walkersville Pharmacy on July 28, 2019 in Windsor, Ont.

If you’ve ever burned with frustration while trying to get your health insurer to cover a medical expense, you might identify with Stephanie Pierce.

Through her employment as a credit union teller, the 34-year-old Elliston resident is a client of Optima Health. Her insurance plan is somewhat less than optimal, though, especially for someone with Type I diabetes. Doctors diagnosed Pierce at age 5.

Pierce’s insurance plan carries a $5,300 deductible, which means she pays everything up to that. After she meets the deductible, her co-pay is 40 percent, until she reaches the individual out-of-pocket maximum, $6,550. At that point, Pierce is supposed to be fully covered at 100 percent.

Most years, she has not reached the out-of pocket maximum. Most years, she doesn’t meet the deductible, either. But this year she did. In February, Pierce underwent wrist surgery on her right arm. In April, she had the same surgery on her left arm. Both were to alleviate carpal tunnel syndrome.

By April 18, Pierce had paid $7,533.73 out of pocket, most of it for her carpal tunnel issues. In May, Optima Health sent her a letter notifying Pierce she had reached the health plan’s out-of-pocket maximum.

Pierce and the doctor who treats her diabetes celebrated that milestone. It meant Pierce could afford two brand-name types of insulin her doctor recommends.

Normally, Pierce can’t afford the name-brand stuff, which would cost her almost $1,900 per month, she said. She makes do with far cheaper generic insulin she gets from Walmart. But that’s not nearly as good at controlling her diabetes, she told me.

After she reached the out-of-pocket maximum in medical expenses, the name-brand insulin was covered, so Pierce started getting the good stuff. That was in July, she said.

Then August rolled around and Pierce got another letter from Optima Health. It informed her that, because some bills from her wrist surgeries had been reprocessed, Pierce no longer met the out-of-pocket maximum.

Pierce would have to pay another $1,466.27 before her out-of-pocket maximum was met, the letter said. It arrived two days before she was supposed to pick up her next monthly insulin refill. In a panic, she called her doctor, who was able to round up some free samples to tide her over. The other option was for her to go back to the not-so-good generic insulin.

She contacted me about all this Sept. 4.

“I have every bill, every [Explanation of Benefits form], every letter, etc. showing I had met the deductible!” Pierce wrote in an email.

“I tried explaining to [Optima] why this wasn’t right and why I shouldn’t still have to pay more again towards medical expenses,” Pierce said. “Optima let me know they couldn’t help me with this problem and that I can call back in 45 days to see if the claim has been ‘reprocessed.’ ”

She added: “I am not looking for sympathy, I am looking for a voice to help citizens stand up to the insurance companies. How many other people are going through the same issue I am?”

Optima Health is owned by Norfolk-based Sentara Healthcare, a large nonprofit corporation. Sentara owns 16 hospitals in Virginia and eastern North Carolina. Sentara also owns imaging centers. Like Carilion Clinic, it employs doctors ranging from family practice physicians to specialists.

Via email, I contacted Sentara on Sept. 4 about Pierce’s complaint. Within minutes, I heard back from Liz Vandendriessche, a Sentara spokeswoman. She said she would look into it as soon as she could. However, she added, “our teams are very busy with emergency preparation plans for Hurricane Dorian.”

That was understandable. At that point, the hurricane looked like it could do major damage to North Carolina’s Outer Banks and the Norfolk region. I told Vandendriessche there was no rush.

More than a week passed, and so did the storm. On Sept. 12, I contacted Vandendriessche a second time. Once again, she emailed back within minutes.

“Yes, I am working on this now and hope to be back to you soon,” she wrote.

That same day, Pierce emailed Vandendriessche and gave Sentara explicit permission to share with me “any and all information” regarding Pierce’s health insurance. That was key because federal law prohibits health insurers and providers from releasing such data without a patient’s permission. The penalties can be severe.

Pierce’s email included her cell number. She encouraged Sentara to call her if the healthcare provider needed personal assurance that sharing the information was OK.

This past Tuesday night, I emailed Vandendriessche again, and told her my deadline for comment from Sentara was 3 p.m. Wednesday. I heard nothing by then.

However, Stephanie Pierce had. After the Sept. 12 email exchange, she received a letter from Optima in the mail. Dated Sept. 5, it said Pierce had met her health plan’s out-of-pocket maximum and that, moving forward, 100 percent of her care would be covered.

She also got a call from an Optima representative, who offered to assign Pierce to a case manager.

Pierce declined the offer, but said she used the occasion to unload her frustrations. She felt peeved she had to get the media involved to get Optima’s attention.

“I told her that, isn’t it ironic that after I had the guy from The Roanoke Times call you, you called me,” Pierce said Tuesday. “ ‘If Dan Casey hadn’t contacted you, I’d still be up a creek without a paddle. I just find it miraculous that it took the media to contact you, and all of a sudden I get my insulin.’ ”

Why did Optima reverse its May determination that Pierce had met her out-of-pocket maximum? What happened to cause the company to reverse it again in September, one day after I contacted Sentara?

At 5:02 p.m. Wednesday, Vandendriessche emailed me this non-answer.

“Optima Health is committed to providing comprehensive coverage for the communities we serve. Healthcare insurance is complex and there are many factors that impact a member’s care and experience. If a member has a concern, we welcome them to use the processes we have in place to address issues and our team members will work diligently to rectify the situation if necessary.”

Of course, the timing could be a big coincidence. There’s no way to ascertain whether my reaching out to Sentara had a direct effect on Optima’s determination that, once again, Pierce had met her plan’s put-of-pocket maximum.

But at the least, it appears Pierce will be getting the good insulin at no out-of-pocket cost through Nov. 30. That date’s the end of her health-plan year.

After that, Pierce told me, she’s going to begin buying brand-name insulin in Canada. Even though it’s American-produced, she can get the good stuff from Canadian pharmacies for a little more than $200 a month, she said. It would cost her roughly $1,700 a month more here.

But that’s another story, and yet another health-care outrage in a broken system that seems full of them.

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Dan Casey knows a little bit about a lot of things but not a heck of a lot about most things. That doesn't keep him from writing about them, however. So keep him honest!

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