Man learns the difference between Harvard Vanguard and Harvard Pilgrim the hard way

Louis Gudema posts a copy of a letter to the CEO of Harvard Pilgrim, which is refusing to pay more than half the cost of an emergency eye procedure even though an eye specialist at Harvard Vanguard told him he needed to get to Mass. Eye and Ear right away or risk having his retina detach. Seems Harvard Pilgrim doesn't agree it was an emergency, and it doesn't pay for "routine" care at the infirmary.

Apparently, although I was told specifically to go to Mass Eye and Ear’s emergency room by Harvard Vanguard, I was expected to check with Harvard Pilgrim at 2AM on a Sunday morning to see what was and was not covered there. Even if I had tried check with Harvard Pilgrim at 2AM on a Sunday, your website does not list a weekend or emergency number. How could I have gotten an approval?



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      Eh, don't worry. In a few

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      Eh, don't worry. In a few years this kind of treatment will be entirely unavailable due to healthcare rationing and cost controls. Try getting that kind of emergency eye care in Canada or the UK at those hours on a weekend. Doesn't happen.

      Always nice to see site visitors from other parts of the country

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      Welcome! No, don't worry, I'm not checking your IP address or anything. It's just that here in Massachusetts, we've had Romneycare, you know, the thing Obamacare is based on, for several years now and I swear, I don't know a single person who's had to appear before a death panel yet, which you'd know if you actually lived here. In the meantime, enjoy our fine foliage.

      ^^^ LIKE

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      I cannot like this enough as I say the same damn thing all the time

      and of course, he's wrong about Canada. None of my Canadian friends ever say they've had to wait in lines or not have service on the weekends, or wait in line for surgeries and what not. It's totally false.

      Now talk to a Canadian how American health insurance works, they are liable to go into convulsions...

      You obviously have never

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      You obviously have never needed specialized ER treatment in a foreign country. To keep costs under control many of the fancy pants things common in the US are not available without a long term appointments. Look at how few MRI machines and air ambulances Canada has per capita compared to the US. Other countries have excellent GP care because of socialized medicine but horrible to nonexistent specialty care. In the US there's every incentive for specialty care at the expense, literally, of primary care.

      Differs by region

      Although the relatives in Alberta piss and moan about it, they won't trade their health care for the lack of health care access the US has for the world. They see these issues as "problems to solve" not "reasons to scrap the system".

      If you need specialty care you WILL get it. If it is elective or not emergent, you have to wait. Life threatening things - like my brother's brother in law's critical care issues - are seen to IMMEDIATELY without wait.

      We're talking tea-party sympathizing supersober farmers here ... and they know that farmers in the US don't get healthcare.


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      In a few years when we finally institute single-payer (you know, like the rest of the first world), this type of problem won't exist at all. That kind of payment system is *exactly* the cure for the problem he had. You shouldn't have to hear "sorry, but you didn't ask one of OUR doctors, so we're not paying".

      Instead of having to deal with whether Vanguard or Pilgrim or the Cross or the Shield agreed to the treatment, having the word of the physician that it's an emergency tells the single payer system that you get the treatment as an emergency. Fewer people die this way because they don't have to wait to meet with their doctor. Fewer people go bankrupt because they had to choose treatment over the system. Fewer people draw insane profits off of the fact that you're sick, so costs go down as well.

      But yeah, I'm sure your dystopian future is more likely...even though the rest of the world hasn't fallen apart yet. You know, like how people thought gay marriage would signal the end times (it hasn't), ending the war in Iraq would mean more terrorism in the U.S. (it hasn't), legalizing pot would lead to bedlam in the streets (it hasn't)...

      Been there, done this

      We paid a $100 at the general ER and then another $100 copay at Mass Eye and Ear ER for my son when he smashed his face taking a tumble in the woods while running down a hill. They tried to say it was not an emergency even though another emergency room sent us there. I complained loudly and they paid it.

      I think Harvard Pilgrim has a beef with Mass Eye and Ear and is taking it out on the patients. Denying that ER care at MEEI was an emergency and refusing to pay seems to be their standard operating procedure. Either that, or they have some total a$$hole in some small department who needs to be everted through their pharynx.

      Get the doc's recs in writing

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      Dude should get it in writing from HV.

      Here's HP's policy:

      Emergency Care are services rendered when a member has a physical or mental medical condition, manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent lay person, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in ... serious dysfunction of any bodily organ or part

      I think it's reasonable for a layperson to expect serious dysfunction of an organ if a doctor tells you to go to the ER right away, and the ER tells you to get treatment within 8 hours.

      Recrafting the argument in HP's terms might be more successful.

      Harvard Vanguard

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      does all their referrals digitally. I went there for years, and any referral I wanted, they'd do in the computer. It was super-convenient, but I was constantly checking them against my insurance since they'd be like, "Nah it's cool, totally, we have it in the computer!"

      And frankly, it's a complete scam to expect someone dealing with a serious injury to be proactive about getting proper documentation. "Hey Doc, my eye's falling out, can I just please get that in writing before I hop over to the hospital? I'll just hold my eye in while you write, thanks. What? You can't ethically let me sit here and watch you write while my eye's falling out?"

      Not everyone can drop everything at the onset of illness to wade through paperwork, and not everyone has a buddy calm and free enough to do that. It's ridiculous.

      Harvard Vanguard Factory

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      I was a patient of Harvard Vanguard, too. When I had a question I was connected to one secretary after another. If they want to provide better care, the doctors will have private voicemail that patients can call directly. Also, when choosing a specialist with them, patients should be able to phone that specialist to ask directly if he/she has adequate knowledge with their health challenge. I had to wait over a month for an appointment with only a photo and "profile" of the clinician as basis for my choice. When I finally arrived I found out the specialist had no knowledge, so I was back to square one. Delays such as these can cost people days off of work, lost productivity, and can even cause worsening health, medical emergency, possible death, and permanent damage. All they had to do to avoid what happened to me (kidney failure) was to be honest over the phone instead of selling me inappropriate medical services.


      Prudent layperson. That's the policy part that I used to make them pay for the visit.

      Note that the "prudent layperson" policy arose when HP wouldn't pay for an ER visit because somebody with all the classical heart attack signs went to the ER and it turned out not to be a heart attack - and they tried to refuse payment. This standard of care resulted from a lawsuit based on this same sort of bullshit.

      Go ahead - rub their nose in it. They deserve it,

      Its a good time to remind

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      Its a good time to remind people that not being able to get insurance (because of cost, a pre-existing condition etc.) would mean paying 100% of the costs. A leading cause of bankruptcy in this country. Its great that you don't have health insurance Will, but many people are looking forward to being able to get it, and many people in MA, including many self employed people like myself, who were unable to get health care before the MA law, are happy to have it.

      When were people unable to get health insurance?

      It's always been available to me. I just don't buy it because it's an awful investment.

      Yeah, I'm fixing to pay $200 a month in case something bad happens, with a private business holding the money and making money off the float for themselves. If anything, "mandatory insurance" should entail me keeping the money in a trust and keeping the interest for myself, not paying it to some company. But, of course, my way doesn't perpetuate the employment of thousands or reward a lobbyist.

      If it were $50 a month, I would be all in, and we wouldn't be having this talk.

      Will, in what alternate

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      Will, in what alternate universe do you figure that the revenue generated by $50 or $200 a month is going to fund your treatment for a catastrophic illness? You need a bone marrow transplant because you are diagnosed with leukemia you are going to need to cough up well over $1M.

      People not understanding basic concepts like pooled risk make governing by democracy more difficult.

      Good for you

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      I on the other hand have a wife and kid. I would prefer to be around for them and not bankrupt ourselves in the process of staying alive. You are free to refuse treatment if that's your choice. The rest of us have lives that aren't quite so lonely and miserable, so please don't pretend to think you know what we want or need.

      Tell you what

      I won't pretend I know what you want or need, and you won't pretend that I'm lonely or miserable, which I am not. Deal?

      You're right

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      I have no idea if you are really happy. But I can say with certainty based on the totality of your posting that you are clueless about how the world really works.

      Using that as an argument

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      Using that as an argument against universal health coverage is useless, as most people would prefer to live and, presumably, people in your life would prefer YOU to live. Do you only want to pay for insurance if you have dependents one day? You seem to be implying that there is no situation under which you would like to survive life-threatening injuries or illness, and that just sounds silly. Even if it's true, it's not adding to the general discourse of how to make health care work for everyone else who likes living.

      You know what would make health care cost less?

      Having more people that can provide it. That's the real answer to this problem.

      Forced insurance is a lazy Band-Aid for a much larger and serious problem. Why our society looks at something like a bone marrow treatment costing $1,000,000 and responds by saying "let's prop up another entire industry and force people to patronize it" instead of saying "let's make that cheaper on the surface" is beyond me.

      Everybody crows about how the ACA "makes it so that everybody can get insurance." Well, maybe insurance is the problem. They're not in business to pay you back out. We're trying to improve CARE by involving businesses that DON'T CARE. How does that not sound completely (expletive) to everybody?

      Not an investment

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      There's your first problem, Will. It's not an investment. It's a financial intermediary. People who need to pay large sums of money when they require healthcare are connected via the insurance company to people who are paying small sums of money on a regular basis so that if the roles are reversed, the large sum of money will be made available to them. That's not an investment just like your car isn't an investment; it's a declining value purchase.

      You aren't buying insurance so that all your little sums of money will be pooled on your behalf for your own use later. You're buying it so that when you need to use it, everyone else's small sums of money go to you. The rest of the time, your small sum is being pooled for someone else's use. It's an economy of scale where as long as there are a lot of people paying in, then the few people who end up in a catastrophic situation aren't left to die for failure to have any means of coming up with a financial solution.

      What trust fund balance do you think you'd accrue alone at $200/mo such that in, say, 2 years you could pay a $100,000 medical bill? So, your proposed system that fits the way you see this all working better doesn't provide the actual values necessary. Nobody could afford to be ill and everyone would have put away $5,000 separately and been unable to use it since nearly all of them weren't ill in those 2 years. This isn't a health fund for paying for your dental's protection against unpredictable catastrophe on a scale you clearly can't imagine.


      They're forcing us to deal with Harvard Pilgrim? News to me.

      I'll play nice with you

      Because you had the balls to use a real name. And if it's a character, I've never heard of it.

      "These people" = any company that sells health insurance and bought their way into making the rules in this country about how healthcare is bought and paid for. I don't trust a single one of them.

      EDIT: Ah, the French for Spongebob. Should've concluded that. Whatever, you're alright.

      Also a good time to remind Will

      ... that Faith is blind, but Karma is a female dog.

      If you had a previously undiagnosed heart abnormality blow up on you (aka Teddy Bruschi), you'd suddenly be the biggest supporter of this. Guaranteed.

      You know what?

      I would rather die and bequeath the assets to my brother. Why suffer? Why can't I just die in peace if that happened? Jack Kevorkian had it right the whole time. Why did we as a society vilify him?

      At least you admit you don't care if I live or die

      A shame that one cannot win elective office by admitting that to people. And honestly, we just need to have people be straight up honest and admit that they don't care about the well-being of people they've never met for health care to really work in this country.

      Yeah, it's really unfair that

      Yeah, it's really unfair that people prefer to vote for candidates who might improve their lives instead of candidates who don't give a flying fuck, isn't it?

      The wrong way 'round

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      Harvard Community Health Plan didn't split. It merged with Pilgrim Health Care in 1995. Harvard Pilgrim is a not-for-profit.

      Now a "for profit"

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      Havard Community Health Plan is defunct. The doctor's group became Harvard Vanguard which is now owned by Atrius Health a For Profit company.

      Harvard Pilgrim is a health insurance company.

      The state healthcare

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      The state healthcare regulation made it a nonviable business entity under its previous organization. Most insurance companies restructured accordingly to continue operations following the passage of Romneycare.

      What I might try

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      I would have the referring eye doctor write a letter about why he considered it an emergency and send that to Harvard Pilgrim.

      Understanding Health Insurance

      While what this gentleman went through is common and unfortunate, it's a byproduct of not understanding one's own health insurance plan. They're complicated, and most people don't get it.
      First, his primary care, or the doctor covering his primary care late at night doesn't A) know what kind of insurance the patient has nor B) cares what type of insurance he has. The MD suggested the pt go to Mass Eye and Ear for an eye issue. It is a patient's responsibility to know (not making a judgement here; it's simply the language used in plan benefit docs and whatnot) what facilities are in or not in their network. Mass Eye and Ear was not in this patients network and he went there anyway. While the Member Services phone line was closed at that time of evening, the website certainly works for checking available in-network facilities. MGH, Brigham, etc are all in any HPHC network. The gentleman could have gone to any of these.
      Second, HPHC actually paid for a portion of the OON ER visit at what is called 'reasonable and customary charges'. These approximate the reimbursement that a similar contracting facility would get for the services rendered. The remaining balance is being 'balance billed' to the patient (a contracting, in network facility by contract would not be allowed to balance bill) as they are allowed to do. Some insurances will cover a balance billed charge for an OON ER visit, others don't. Right or wrong, it's allowed.
      Third, the decision surgery was required was made at 2am, but was performed at 10am. While it was certainly necessary, insurance looks at 'emergency' care as a life or death thing. If the surgery was a true emergency, it would have been done at 2am and not 6 hours later. Again, not making a right or wrong judgement here- that's just how HPHC looks at it.

      This stuff happens frequently to people- they simply go where they like without checking the available options and end up getting screwed. (I am willing to bet that this gentleman also signed a waiver of financial responsibility before his procedure, but left that out) This guy simply did what his doctors told him to do (most of us would) without realizing that the doctors don't know every patient's insurance and available networks and stuff off the top of their heads. Sucks, and I hope his appeal works, but it pays to understand how your plan works.


      The TL;DR version: just because a doctor tells you to go somewhere doesn't mean your insurance will cover it. Know your plan.

      In network

      I just checked, Mass Eye and Ear is considered in network for most of HPHC's plans (although not all- and I suspect he doesn't have one of them- too bad he doesn't tell us).

      In terms of the ER charges- if he has a plan with Eye and Ear in network- he might not understand that the ER billed 10k for his ER visit, but is only getting back 5k in contractual rates less pt responsibility (copay, deductible, etc). People look at an explanation of benefits all the time and misunderstand that the difference in the billed amount versus the reimbursement amount is absolutely inconsequential at an in network provider. He's responsible for only either A) a copay or B) a deductible for his ER visit. That's it.

      And hell, if a procedure is being performed by an in network provider at an in network facility that requires authorization and that auth is not obtained- the provider has to eat that.

      All well and good, but ...

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      He mentions he's been a Harvard Vanguard patient for 35 years. That means he started out when there was Harvard Community Health Plan, and it was good - and the insurer and the doctors were all the same. And then came Pilgrim, all the splits and reorganizations and now we have something with a name that bears an unfortunate similarity to that of a cigarette company running the "traditional" HCHP clinics, only now they take pretty much all kinds of insurers, some of which may have beef with downtown hospitals. I can see how somebody in a position like his would miss some fine print buried in one of those 20-page "important notices" they send out that nobody reads.

      Even as somebody who is very aware of the difference (we're also longtime HCHP types; losing company-paid insurance when you get laid off makes you have to navigate stuff like this), I never would have thought that my insurer would refuse to pay for what the on-call urgent-line person told me to do.

      I never would have thought that my insurer would refuse to pay

      Most people don't, which is the problem. It sucks- but this is just how the insurer looks at it.

      I hope HPHC takes care of this for this guy, and it's ridiculous that he has to go through all of it. Personally I wish it was easier and less confusing to navigate, but right now it is what it is. Hopefully it changes soon.

      Adam, it's worse than you

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      Adam, it's worse than you describe.

      They're paying half the cost of the ER visit, but *none* of the cost of the surgery.

      Harvard Pilgrim contacted me and they will provide coverage

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      I'm the person who sent the letter to Harvard Pilgrim CEO Eric Schultz. Today I received a call from an assistant to him letting me know that they had received my letter and would provide coverage. Apparently they still had not noticed my posting of this open letter, or the many responses on UniversalHub and elsewhere -- over 1,000 people read that open letter. I comment on Harvard Pilgrim's lack of social media awareness in a blog for Econsultancy

      I appreciate the response from Harvard Pilgrim and their covering of the procedure.