Our family spent last summer in the Snowmass/Aspen area.  While there, Camille, my youngest, became ill.  After 5 days of vomiting and hardly eating, I felt we needed to see a doctor, just to rule out all the scary things that could be the cause.  Like the good little Kaiser Permanente member I am, I called the appointment people and asked “What to do?  I am out of the service area!”  They had me speak to one of their phone nurses, who indeed said “Yes, take her to the doctor right away!”

The KP person told me that I would have to pay out of pocket, but could submit the bill for reimbursement.  I asked that it be noted in the chart that I called and did everything right, so when I submitted said payment, I would be reimbursed no problem.

As this was not a life or death situation, I did not want to take Camille to an ER.  I didn’t know of any urgent care in the area, so I called a pediatric practice 40 minutes away.  They could see her that afternoon.  “Great!” I thought, “I’ll save Kaiser money by not going to the ER!”

Now, its 9 months later.  I submitted my paperwork for reimbursement in December(I had misplaced it).  In February, I received paperwork denying my claim.  What grounds?  Code 711:  Service, Procedure or provider not authorized, member liability  .  Whhhhaaaattt???  All my hoop jumping and they are denying my claim?

I hadn’t had a chance to contact Kaiser until today(sick relatives, morning sickness, a family bout of influenza takes it out of a gal).  I called and talked to a nice young man.  Apparently this is standard practice.  You know, not covering something they are liable for, in the hopes that you won’t question the all powerful HMO.

But if I *had* taken her to the ER, they would’ve covered it no questions asked????(so he says—I think I would’ve gotten stuck with the bill b/c it was a “non emergency” and Kaiser is extremely clear about how they feel about ER usage outside of network).

So, by doing research, finding a regular pediatrician to schedule an appointment with, and in essence saving Kaiser at least $1000-$2000 dollars(we are talking Aspen, here) I get the shaft.  I have to jump thru even MORE hoops to get my money.

I have to have my pediatrician “retro-approve” the visit.

Then I have to call claims back and re-argue with them why they need to send me my $169.

Goes to show you—QUESTION EVERYTHING FROM YOUR INSURANCE COMPANY.  THEY AREN’T IN IT TO TAKE CARE OF YOU, THEY ARE IN IT FOR THE MONEY.