Friday, January 25, 2019
MANAGE NURSING CARE AT HOME, "Employer Medical Coverage"
CHAPTER 8 EMPLOYER’S MEDICAL INSURANCE: OUR EXPERIENCE (Cooper, 2011)
I [DWC] worked for
for a decade, from 1983-1993, and was covered during that time by their Empire
Blue Cross/Blue Shield policy at work and for another decade after taking an
early retirement buy-out that included their continuing medical coverage. What follows is as brief summary of that
experience, along with what happened with the successor insurance companies,
MVP, and then United Healthcare, which companies IBM
contracted with to manage the medical coverage for some of its retirees.
CROSS / BLUE SHIELD, 1983-2004
While I was working at
most of our medical costs were quite routine and well covered by their health
During the 100-days’ war against Tina’s aspiration-caused pneumonia, from February to June 2004, we ran up roughly a half-million dollars in hospital expenses, covered by
policy with Empire Blue Cross/Blue Shield of New York State. When she returned
home, round-the-clock skilled nursing was similarly covered, without a problem
by Empire BC/BS, whether the billing came from the nursing agency or from me.
INSURANCE BLUES: MVP, 2005
One must sometimes fight one’s insurers.
At the start of 2005 we were moved by
IBM from Empire to MVP. We started round-the-clock skilled
nursing care with an agency in June 2004, and I started hiring nurses to fill
the gaps in the agency coverage a few months after we began this. By January
2005, I had taken over hiring the nurses, at a higher salary than the agency
had been paying, then training and managing them, and billing the insurers for
a cost mid-way between what the agency was charging and what the nurses were
receiving; I was changing what our actual cost was.
MVP wanted more documentation than Empire had required. We sent them reams.
MVP wanted to stop paying for the skilled nursing at home, labeling Tina’s need as “custodial care” rather than “skilled nursing care.” Custodial care is roughly equivalent to babysitting, which would include giving bottles and making diaper changes. Tina was on a ventilator, fed through a gastric tube, quadriplegic, and in pain if morphine were not given in proper amounts at proper times. There were about a half-dozen prescription medications to be given at various times during the day and night. The gastric tube needed daily care. The tracheostomy needed daily care.
All activities needed to be documented, to assure they were done, to provide continuity of care from shift to shift. We had hospital orders for all this, along with a doctor’s orders as well. Still, MVP carped. They planned to stop paying for daytime skilled nursing care. They refused to pay for overnight care.
From 10:00 p.m. to 8:00 a.m., through all of 2005, I was the overnight nurse, resting beside Tina, getting up for the administration of medicines, answering over-pressure or under-pressure alarms from the ventilator, suctioning secretions from her trachea, changing her disposable diapers by rolling her carefully on the bed while keeping from hurting her tender wrist joints.
I do believe “work is love made real,” and this was a labor of love. The loss of sleep was less a problem than was the fear that I would be alone when we lost electrical power, as we do several times each year here, or when she had an emergency condition requiring my immediate attention and my calling for help simultaneously. Evacuating her from a fire would be terribly difficult alone, too. Walking the dog briefly or checking some questionable condition outside meant abandoning her. Not good, not good.
We appealed the proposed removal of MVP financial support for the daytime nurses, and we pushed for overnight skilled nursing as well. Two levels of MVP reviewers turned us down. Two levels of
IBM reviewers turned us down. An independent
outside medical review, our last hope, vindicated our position entirely. Yes,
one must sometimes fight.
We had started replacing some of the agency nurses as early as August 2004. By January 2005, I believe, we no longer used the agency. We started hiring overnight nurses in January 2006. MVP was slow to pay, getting behind a month or two for much of the year. At $25,000 per month, this created a significant cash-flow problem.
Next, we were switched by
IBM to United Healthcare (UHC), the group we are
with now. They were less demanding than MVP, and more helpful; but the
transition delayed our reimbursements (we pay the nurses, weekly, ourselves)
for two or even three months, amounting to $50,000 to $75,000 in arrears. I
fear that few other couples would have had the savings we had that let us cover
this shortfall. Eventually, UHC caught up, to our relief.
Thank you, United Healthcare.
THANKS TO IBM
In the decade since 2005,
IBM has paid more than five
million dollars for Tina’s care. My decisions to work for IBM and, ten years later, to take their
early-retirement buy-out, paid off for us. We are greatly appreciative. The ten
years I worked for IBM proved to
be the best working situation I ever had.