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Nazareth, Pa., United States

Wednesday, September 16, 2015

NorCo Worker Deals With Illness, Insurance Denials

I'll call this guy Jim. He's a long-time employee of Northampton County, and does not mind paying a bit more for his health insurance. "You can take 10% of my salary and I don't have a problem," he told me last night. "But when my wife can't get coverage, then I have a problem." Unfortunately, that's the problem he's facing right now, thanks to changes in the health care plan provided to workers by Executive John Brown,.

Married for 24 years, Jim and his wife are currently putting their child through college. as anyone with kids can tell you, that's an expensive proposition. "We're back to living paycheck to paycheck," he admits.

No time is the right time for someone to become sick, but it has happened to his wife. Recently, she began experiencing bloody bowel movements and was not feeling well. She eventually ended up in the office of a gastroenterologist, who is concerned. He has ordered a colonoscopy and a CAT scan. He also prescribed barium for the procedure as well as Nexium for the acid reflux that has accompanied his wife's other symptoms.

And Northampton County's medical insurance carrier, in its infinite wisdom, denied coverage.

Now the insurance provider quickly reversed itself on the colonoscopy and CAT scan, but still refuses to pay for the barium medication needed for the colonoscopy. It also is refusing to cover Nexium, telling this guy's wife she can get it OTC.

Fortunately, the doctors are involved and are going to discuss this denial with the insurance provider. But in the meantime, this guy is a wreck. He told me that if he pays for the medication himself, he will be $400 out of pocket.  

According to Jim, this is not the first time. Last year, he was denied coverage for the removal of a lump in his chest. The claim administrator had denied coverage, arguing it was cosmetic It took a lawyer and doctor tag team before the insurance changed course.

For Jim, the excised lump was benign..But changes to these health plans are a cancer on the morale  and health of the county workforce.

43 comments:

Anonymous said...

We need to decouple healthcare and employment in this country. It's easy for Jim to blame the insurance company or the bureaucrat but it's the system.

Under the current system what's happening to Jim is the only outcome available, every entity is looking out for their own self-interest(thank you very much Ayn Rand).
The bureaucrat needs to save money or at the very least spend money on those with the greater influence in the community, the insurance company needs to make money as does all the for profit healthcare institutions, there are stockholders to be satisfied.

The problem with the current path we're on, that is, health insurance for everyone is making it worse. Here's Jim with his healthcare insurance only to find out what he and we all need is Healthcare.

Capitolism and capitalist should be nowhere near a healthcare delivery system.

Bernie O'Hare said...

I may be mistaken, but think Jim is blaming the system, in which bureaucrats overrule decisions made by physicians, and in triplicate.

Anonymous said...

Those bureaucrats are not overruling the healthcare decisions the doctor is recommending, just who should pay.

I suppose the doctor could do it pro-bono, or the insurance company could make less for it's stock holders. or Jim could pay for it.

Or maybe we could all share in Jim's loss and have national healthcare for everyone.

Anonymous said...

Why the Hell should health insurance pay for an over the counter drug? Nobody's insurance pays for something you can just buy. Next will he will want it to pay for his aspirin?

With this bitching and his previous whining it sounds like this is just another county public teat complainer who is worse than usual.

Bernie O'Hare said...

I realize you have no compassion, but what bothered me more than anything was the distraught nature of this worker, who no longer has the comfort of knowing whether his wife will receive adequate care. To a person like you, who has a void in your heart, this means nothing. But to people with loved ones, something like this is disconcerting.

Anonymous said...

3:10am roots for the casino to win.

He went all "suck it up, cupcake" on Jimbo.

Anonymous said...

Our system is rigged for profit not for health. Either bureaucrats decide your fate or Insurance accountants decide your fate. The right wing is all in on the insurance accountants giving a shoot about your health and left wings is all in on the bureaucrats.

Obama tried to fix it but the best he could do with the Congress is get to ensure Insurance companies get business. With idiots like Palin going on about death panels. We are a dumb country. Hell, why else would a Donald Trump even be considered to run our nation. His finger on the button??Yes there is still a button to end the world

Without doubt we need some sort of proinmary care single payer system in America. A system without all the nonsense paperwork. The poster at 1:54 is right. Capitalism is fine for cars and toasters, you have to settle for what you can afford. No harm no foul. However,that is a piss poor way to deal with healthcare. As it stands today if you have nothing you get Medicaid if you are old you get Medicare and a veteran gets VA, all publically financed healthcare. The only losers are the shrinking middle class and oldsters with the complicated and expensive supplemental plans.

Enough already, our system is no longer tied to 20-30 year employers with fulltime jobs. Time to join the 21st century and the rest of the modernized world. Sorry big Insurance companies but just like loan shark middlemen you need to go.
There is not one country that has those systems that when asked would even consider the American way. Yes, even the wealthy who will come to America because we have more specialists per capita than any other country. On the other hand we have the least primary care physicians than any of those countries. So if you are from
England or Canada and loaded you can see a specialist in America tomorrow. If you are not loaded you will wait until your health is shot and then you will see the specialists and you will pay through the nose.

That is why we need easily accessible primary care for all Americans. It is about time.

Anonymous said...

I'm sure the barium is expensive, but nexium is like ten bucks...

Bernie O'Hare said...

The OTC cost of Nexium is about $160 per month. I believe the barium swallow is about $400+

Anonymous said...

boo hoo - just another hack job toward brown from bo. health care is not a right. when times are tough the tough get a second job. they don't sing cry me a river to a bum blogger

Bernie O'Hare said...

I refer you to my comment above.

Anonymous said...

staffmark is having a job fair

Bernie O'Hare said...

Perhaps you should go for another job at which you will last three weeks.

Anonymous said...

Bernie, this link might be of value reduced Rx nexium for uninsuered or insured whose insurance doesn't cover full cost Devil in details but worth a look.

https://www.purplepill.com/heartburn-relief/purple-plus-savings-card.html

Bernie O'Hare said...

Thanks. This guy is no crybaby. He loves his wife, and am sure he is distraught over her illness. I hope she makes a full recovery, and would suggest that Brown have a sit down with the third party health plan administrator.

Anonymous said...

Nexium is OTC and is more like $20 a month. Once again you are fabricating a story to suit your anti-Brown agenda.

Anonymous said...

Walgreen's has a 42 pill box of Nexium for $22.99. Just make stuff up O'Hare.

Anonymous said...

Oh please show some compassion! Why should NC employees have to pay for an OTC acid blocker? Why should they have to pay for Tums, Pepto-Bismol, Clariton, aspirin, Nyquil or any other OTC medications? Have we no heart?

Bernie O'Hare said...

8:49, That is 14 pills and is 1/3 prescription strength. To get the same relief, you would need 6 boxes over 28 days, and that costs $136.14. It does come out to about $160 per month.

8:58, aka Mezzacappa,, you don't understand the meaning of the word compassion.

Anonymous said...

You clearly stated that this woman had acid reflux. There is no need for prescription strength for simple acid reflux. Look it up on the Nexium site. You are trying to make a case where it doesn't exist. And no, I am not Mezzacrazy. Just someone who has had to pay for these same meds out of pocket for years and resents this employee for whining about it.

Bernie O'Hare said...

Yeah, you are her. I clearly stated that a doctor prescribed this. That is three times the strength as OTC. Now you are countermanding what a doctor prescribed bc you are a cheap fuck who wants everyone to be miserable bc you are.

Anonymous said...

Since 1974 real wages for 99% of Americans have increased 2% vs. over 168% for the top 1%. Those miserable critics of county employees should direct their wrath in another direction - the conservative Republicans who want to cut taxes for the wealthy and propose a health plan is simply stated - your health isn't that important its not a right (like your 2nd Amendment distorted right to bear arms) so die without any care.

Anonymous said...

A person who resorts to profanities in defending his position has already lost the argument. You basically ended the argument by calling this poster a "cheap fuck" and taking down a subsequent post. You have lost the argument.

Anonymous said...

People have been conditioned in American. You can see it everywhere. Since Reagan and his trickle down corporate economics, we all believe near poverty is the American way. We accept the gross income inequality our parents fought against and would not tolerate.

Between Fox, right wing nut websites and mainstream outlets we have been told that the poor are the problem, the unions are the problem. Meanwhile real wages have gone down, costs have gone up and overall profits, productivity and upper-class wealth has skyrocketed.

You know the old saying drape a flag on shit and you can sell it to most Americans. What a stupid angry people we have become.

Anonymous said...

4:02 you clearly have it right about the final nail, but the assaults on working people did not begin with Reagan by a long shot.

You would benefit and possibly enjoy reading all the works of Chris Hedges.... but I'll warn you, you'll be swallowing the red pill.

I get what you're saying about the jingoistic flag waving, reminds me of something I heard said, a small boy asked his father, "What's the difference between the people with small flags on their cars and people with really big flags on their cars?" and the father replied, "The ones with the really big flags are the really big assholes and the ones with the small....."

Anonymous said...

lol- love the people on here who claim Northampton county is being run by conservatives. this group is so far from being conservatives that they are almost democrats. this group is gop establishment to the core. this group and the other hacks in the federal elections all over the country , run on a conservative platform ,use the conservative voters, then govern and vote like John McCain.

btw,,, I thought obamacare took care of issues like this. do the country workers have access to obamacare?

Anonymous said...

"Chris Hedges"

Really I do research, The guy who linked Iraq to the 9-11 terrorists and was quoted by Rice and Cheney. Also warns of rampant worldwide liberalism. yeah, I get "his" agenda. You guys need to go a bit deeper than Red state rage.

Anonymous said...

6:35PM
Wiki is the extent of your research? And from that you see his agenda? Your research report wouldn't do very well in any classroom.

I'm not trying to be adversarial, I appreciate you at least googled wiki. Try going a little deeper down the rabbit hole.

... at least go to you-tube if you have trouble reading whole books and multi tasking. Check out: Chris Hedges on the Horrifying Decline of the American Empire.

Perhaps you could recommend a book or video for me. I'd like to understand your agenda.

Anonymous said...

Everybody has a shitty plan and most plans have gotten shittier and more expensive after Obamacare. Life is hard and sucks. Don't vote for Socialists and always wear a cup. We're all getting screwed - no matter who we work for.

Anonymous said...

Hokie Joe says
Northampton County's Health plan is a "self insured health plan". What does that mean?It means that the County hires an "administrator" such as Blue Cross/Blue shield to administer their health plan. The County Executive approves what health benefits are paid for and the administrator pays the bennies and the County reimburses BS/BC for their expenses. When a questionable case comes up the Administrator calls the County and asks them if they want to pay for this medical procedure. All of this comes down to John Brown our Executive. He decides who lives and who dies and who gets medical procedures paid for and who suffers when a certain type illness is questionable for coverage. Thank you John Brown.

Anonymous said...

7:22PM

You are absolutely wrong! Some people have fantastically easy lives and have great plans and some are compensated enough to afford the best and get the best. Just nobody in your social strata, if those like you in your social strata got together to collectively bargain for a better deal, you would be a socialist.

The ones you collective have to bargain with are smart and steal the words and then change the meanings, leaving you unintelligible when trying to describe what's happening. Your statement translates to: Don't join social movements or unions in order to collectively bargain for a better deal, tough it out alone with a cup, and let the boss roll ya.

Anonymous said...

If unions are the answer then we have a moronic question. I see first hand every day how the unions shield the recipient underperformers who demand much and produce very little. People who steal time and piss hot are protected by collective bargaining while those who work hard and apply themselves are ignored. I don't need someone to bargain for my compensation to include my benefits. And I certainly don't need to be lumped in with recipients who clock in and then rail against "the man" while they fail to be productive. I have three jobs and I am quite content that in each of those jobs I have negotiated for my compensation. I am an aspiring 1%er.

I also take OTC nexium for reflux and it works great. I buy the generic from Sam's club.

Anonymous said...

10:19PM
You're an inspiration, 3 jobs you say, wow you're a go-getter. I'm sure you'll make to the 1%.

I suspect that when you get there, to the 1%, you will be in the company of the finest sort, there are no 1%ers that "demand much and produce very little" no 1%ers that "walk the dog" or "piss hot" and the 1% "don't need to collectively bargain" or bargain at all really. Maybe you'll even get to meet Sam himself and work a deal on that nexium.

So to sum up, unions are moronic, 99% of us are lazy, drug using, non producers and all you need is 3 jobs, and the aspiration to be a in 1%, the "Elohim".

Anonymous said...

Brown's credibility and electability fell faster and harder than his change to the quality health care plan that his predecessors put in place.

Chatty Cathy said...

Yes it's called Medical Assistance. I heard a doctor calling in a script for ibuprofen when I was in the hospital. She told the pharmacist the Mother told her she would not give it to her child if she had to buy it over the counter. Only if MA paid for a script of it. So keep on downing the working person. He could have never worked a day in his life and demand the doctor to call it in as a script to get it for free.

Chatty Cathy said...

May God help you because their are only a few caring employees left at the County. If you or someone else in your family is aging, has a mental illness, your child or grandchild is born with a birth defect, gets a brain injury or develops an addiction- Good Luck!!!! This administration ran all of the caring workers out. God is the only one who will help you now!!!!

Chatty Cathy said...

Yes I know I have a typo or 2 sorry!

Anonymous said...

Are you f'in kidding me? Sounds like everybody else in the USA. Why should county employees get coverage any different than the average person?

Anonymous said...

10:03PM
If county employees got nothing, what could the "average person" expect?

Perhaps if county employee got it, then the "average person" could, and probably should, expect it as well.

Some folks are like crabs in barrel...

Anonymous said...

"Crabs-in-a-barrel"

Anonymous said...

Way to go JB thanks for the wonderful shit medical coverage you shoved down your employees throat or should I say shoved up there asses, is this the kind of bullshit that you would give to your employees who you to quote are the counties most valuable assets, It wont be long till you are byby. ALSO TO ALL OF YOU OUT THERE THAT BASH COUNTY EMPLOYEES GO FUCK YOURSELF.

Anonymous said...

4:45PM

Poor Jim has troubles and you just made it worse.

That's no way to inspired disciples or win over the masses. If what you say doesn't help win over, or at least make even one person on the other side think twice, your wasting your breath, unless you like singing to the choir.

A county employee is a person with a hundred people waiting to fill his position if he/she f*cks up. Ease up on the roids, take off the truck-nuts, and try not to sound like a mook.

Advient Services said...

I don't see anyone mentioning a Patient Advocate group. There are professionals, like myself, who specialize in these type of issues. Most people pay a tax professional to do their taxes or a Realtor to buy/sell a house. Insurance and billing has so complicated (thanks to regulations), that people need someone in their corner. We offer some free services to help patients and then some fee services for the more complicated. Even if you don't use an advocate, try to use some of our resources to help yourself. https://advient.co/contactus/