My eyes are red. They itch. They hurt. I'm an allergic mess. Even my eye doctor said to me, "God, you look terrible." But instead of ranting about the fight I'm having with my insurance company to get my antihistamine eye-drops covered, I've decided to write that I imagine took place in the corporate conference room of ANTHEM BLUE CROSS BLUE SHIELD that put me in his jam ...
CEO: Jenkins here has a proposal for us on how we can increase profits this year.
OVERPAID SYCOPHANT: Why do we need to increase profits? We're already up fifty percent from last year.
CFO: Last week we voted to increase our bonuses by seventy-five percent, so we're actually in the hole.
OP: I see. Then it makes sense.
JENKINS: A careful review of claims paid on prescription medications last year shows that several hundred people got approved for antihistamine eye-drops, which cost about a hundred dollars a bottle and last roughly three months.
OP: So it's about $33 a month?
JENKINS: That's right.
OP: And how much does the average claimant pay us every month?
JENKINS: The family plans are about $1,800 a month.
OP: So we're making a ton.
CFO: Pay attention, boy.
JENKINS: As I was saying, if we deny all these claims, our revenue increases substantially.
OP: I'm sorry. I'm not getting this. How can we justify denying the claims?
JENKINS: We issue a statement that we strongly recommend the use of over-the-counter eye drops for this condition. Of course, since we don't cover any over-the-counter meds, it costs us nothing.
OP: Do the over-the-counter drops work?
JENKINS: Mm ... no.
OP: Not at all?
JENKINS: Well, they work at least as well as plain water, so that's a plus.
OP: How can we get away with that?
CEO: Actually we can't, but we can create such massive obstacles almost no one will be able to figure out how to file. Is that right, Jenkins?
JENKINS: On the nose, boss. Here's how it works. When a pharmacy calls to find out if the eye-drops are covered, we don't say yes or no. We simply say, "Anthem recommends the use of over-the-counter medication for this condition." About fifty percent of all pharmacists will take this at face value and break the news to the customer, who will either buy the over-the-counter drops ...
OP: Which don't work?
JENKINS: (continues) Or decide to pay the full price for the prescription with their own money.
CFO: And the other fifty percent?
JENKINS: The other fifty percent will call us.
OP: And then we'll approve?
(Laughter all around the table.)
JENKINS: Hardly. Our operators will be instructed to tell the pharmacist that the claimant has to phone us directly to get an override.
OP: What's so funny?
CEO: There is no such thing as an override!
JENKINS: That's right. But again, about fifty percent of the claimants who call will hang up in disgust before finding that out, because we'll keep them on hold for twenty-five minutes.
CFO: Is that long enough?
JENKINS: Usually. Those who hang on for the full time will be told their doctor has to call.
JENKINS: But wait. It gets better. The doctor has to call a special division at Anthem called the Prior Authorization Unit.
CFO: Prior Authorization Unit? I don't know, Jenkins. How much would it cost to set up something like that?
JENKINS: That's the beauty part. All calls to the Prior Authorization Unit will be routed to Tina in accounting.
OP: Who's Tina?
CFO: She's the redhead who works for the brunette who works for Bob, Jack Greed's assistant.
CEO: No she's not. She's the blonde who sits behind the redhead.
JENKINS: Actually, she's the girl who sits next to the blonde who sits behind the redhead who works for the brunette who works for Jack Greed's assistant, Bob.
OP: And what will Tina say when she fields these calls from the eye doctors?
JENKINS: We doubt anyone will ever get that far.
OP: But if they do?
JENKINS: They'll be put on hold.