We're Not Gonna Take It

I am sorry for this image that I have put in your head, along with the song that accompanies it.
I am sorry for this image that I have put in your head, along with the song that accompanies it.

My tolerance for ineptitude is miniscule. I wouldn’t consider it a character flaw. (It’s inherited. Genetic. My father has the same tolerance level.) I’m all for giving people breaks if they are new to a position or might be having a bad day, but if the inability to fix a problem for a client is written (in invisible ink) into a company’s mission, there’s a serious issue.

Insurance companies have a lot of serious issues. I paint insurance companies with a broad brush because while there is always an exception to the rule, I have yet to turn to someone after getting off the phone and say:

“Wow. They’re the best insurance company ever. I’ll be a loyal customer until I die!”

Because they don’t want you to be a loyal customer. They want you to leave when you start to have complications or get serious illnesses. They all hope you’ll be another company’s problem by the time that happens.

You’re technically not even a customer; you’re a subscriber. (Unlike a newsletter or a magazine subscription, you’re not subscribing voluntarily.) You’ve “chosen”” ::cough cough:: a particular insurance company, but really it’s your employer in most cases that does it for you.

Side note: Most employers don’t care about the fantastic experience you’d get from the insurance call center or if you have to jump through rings of fire for durable medical equipment. They want to check a box for the government under ACA (although some companies are happily paying the fine) or add “we offer a medical plan” to potential job prospects. (I think all job descriptions should include a URL to the medical plan they offer, but that’s just me being efficient.)

Insurance companies are not altruistic. They are not charities. They are not there to help you. They are businesses. Businesses that have profit margins and bottom lines and investors. For years, they did everything possible to avoid having chronically ill individuals on their plans. These days, they can’t avoid us. We’re here.

But they are not making it easy for anyone these days to get answers. Or help. They think we’re just going to eventually give up.

My latest foray into the seventh circle of hell (which is reserved for insurance companies) had nothing to do with diabetes (except that it was fun to watch the Dexcom graph rise while I was on hold and seething…), but it did prove to me that sometimes, you have to say that you’re just not going to take it.

The Never Ending Story

I had COBRA for two months while John switched to a new position, waiting for his company’s healthcare plan to kick in. I had a Continuation of Coverage certificate, showing the dates of COBRA coverage. COBRA was through the same company as the healthcare insurance company, just a different department. And that’s there the problem started.

COBRA had put in the wrong date (off by one day) for the end of my coverage. Of course, I had two doctor appointments and lab work on that last day, so the bills came in from the providers. I called the insurance company.

Them: “You had no coverage on that date of service.”

Me: “I have a Continuation of Coverage certificate from your company showing that I did. I’m happy to fax it over to you.”

Them: “We can’t receive faxes. You need to contact COBRA and have them change the date. Then you can call us back and have the three claims reprocessed.”

I called the COBRA department. It was a “data error” and they would update my file to show the correct date.

Them: “It should take just a few business days for the correct data to be updated throughout the system.”

It took five months and over 11 hours on hold/discussing/explaining over and over/cajoling/pleading with both the COBRA department and the insurance company (They are the same company. I can’t stress this enough.) and the date finally got straightened out.

I was told it was fixed by COBRA and that it was the insurance company’s fault for not updating. That excuse was used twice, but then a third person admitted that they hadn’t submit the data change after three weeks and two phone calls. I was told that there was no single point of contact for either company to handle the escalated (by now) issue. I was told that they couldn’t make any outgoing calls and that I couldn’t get a phone number to call anyone. An email? ::insert evil laugh:: Silly woman.

I thought it was fixed. I was told it was fixed.  After five months, it was over. Hot damn and hallelujah.

Nope.

I received a dunning letter from a provider, threatening collection and damage to my credit. Originally, the claim was paid. The insurance company’s “claims recovery” department has asked for the payment back and was not releasing the request, despite the correction of the date. Could I talk with anyone there in the claims recovery department? No. Could I send documentation showing the coverage date? No.

Could I pay the bill to the provider? Yes.

I thought about it. Thought about how I was exhausted, fighting against a company I paid a lot of money to receive benefits that weren’t being given. I was tired of the tinny on-hold music that became the soundtrack of my days. And then I decided I wasn’t going to take it. At this point, I had clocked over 13 hours on this mistake that was not my fault.

Filing A Formal Complaint With The State

I filed a formal complaint against the insurance company with my state. Uploaded my documentation and did it online. I used the word “ineptitude”.

On December 23, almost eight months after the date of service, I got a phone call from a “member advocate” of the insurance company. He was “calling to help me resolve the issue”. He admitted that he was calling because I had filed the complaint with the state. Can you imagine what would have happened if I hadn’t formally complained to the state?

Those of us with diabetes understand that we have to work with constricted formularies, certain types of pumps and meters, get letters of medical necessity and write appeals.

We can choose to wait on hold while Mozart Muzak drones off-key or we can say that we’re not going to take it anymore.

Document. Document. Document.
Document. Document. Document.

If You’re Having a Problem With Your Health Insurance Company

If you’re having an issue with your insurance company not paying claims for services, not providing documentation for denials or appeals, here are my recommendations:

  • Document everything. Hint: Get a notebook just for insurance calls.
  • When the representative comes on the line, ask for their name and identifying ID. Write it down along with the time and date of the call (and even the length of time the call took, if it tickles your fancy).
  • Be respectful towards the representative, who isn’t the individual deciding on your claim status or your appeal or denial.
  • Have your claims documentation at the ready, because they’ll always ask for information.
  • If you’ve got an issue that’s been going on for a while,  allow the representative to take a moment or two to re-read the notes. This will save your breath. 
  • Ask for an escalation if you’re not getting anywhere. There are “escalated claims specialists” that will magically appear on the line who can give you (at the end of the call) a different number to reference as part of the escalation. 
  • Give them time to work the issue, but hold them to the timetable. Some issues are complex, but others should be resolved quickly. 
  • Know that each state has an Insurance Commissioner (and department) who is tasked with protecting consumers. Use them if you’re not getting a resolution after 30 days or if you are not satisfied with the appeal decision. Here’s a list of all the state Insurance Commissioners for reference. 
  • If you have an issue with a provider being paid properly, work with the provider. (They all have resources and recourse against the insurance company, so two heads are better than one.)

As of today, my issue still isn’t resolved. Why? (For those of you playing at home: these people all work for the same company. Just different departments.) The member advocate gave me this excuse:

“I can’t get in touch with anyone in the claims recovery department. I’ve called a few times. I’m trying to make sure they have all the documentation they need so they can stop the request for the refund.”

It’s his turn to sit on hold for a while. I’m not going to take it anymore.

 

 

 

 

0 comments
  1. I was going to suggest contacting your state insurance commission, but…
    Great advice, as always. Hope it gets resolved TODAY.

  2. It’s crazy, isn’t it? Just crazy. My opinion (which I know will be controversial) is this: the USA needs a socialized medical care program for all USA citizens. Yes, it would be paid for by (I know, heaven forbid!) taxes. But how on earth could we afford it? Easy. By removing this insane level of administrative middle management, ineptitude, hassle, and constant paperwork. I lived under the National Health Service in Great Britain for 17 years – 3 years without Type 1 Diabetes, willingly paying (not TOO high) taxes so that my fellow citizens could be healthy (which is morally rewarding, I feel), and 14 years as a Type 1 Diabetic, receiving consistent, predictable, excellent medical care, the need for which was NEVER questioned, because obviously a country benefits from its citizens having good healthcare, and getting back to work. I never had to fill in reams of paperwork, argue over the phone, or answer questions to anyone other than my doctor. It was efficient, and amazing. Those who would argue against socialized medicine have never actually experienced its logic, compassion, and efficiency first-hand. Just imagine how many hours of time people in the USA waste arguing for the right to access things they needs to stay alive. It’s just stupid. Since moving back to the USA, I’ve wasted at least 20 hours trying to get regular medical supplies. I could have spent those 20 hours contributing to the economy instead.

  3. Unfreakinbelievable! No wait, I can believe it but I can’t stand it. I’ve said all along that insurance companies are the problem with healthcare costs/problems/frustrations in this country. Well, the major one anyway. I applaud you for your tenacity and the fact that you are so willing to let others benefit from your hassles. Instead of just bitching about it, you provide some answers for others. Thank you.

  4. Really great advice, but it’s so frustrating that this is the UNIVERSAL experience with insurance companies, and yet it seems nothing is being done to address it.

    1. Maybe the arguments in favor of medical care without insurance companies should be framed in terms of the time and money that would be saved.

  5. Wow, what a meaningful coincidence that I read this, as I just got off the phone with my former employer saying that my Cobra enrollment had been processed and I was good to go. So I’m going to be extra careful and goo over all my statements from now on. (PS Isn’t the Cobra premium ridiculous – how could the average person afford to pay it?)

  6. I’m exhausted and exasperated for you. And also? I’m still chasing down $185 that ExpressScripts has owed me for 6 months. I think I’ll follow your advice and get something filed. Thanks for chronicling your journey for us.

  7. I’m so glad you wrote this. When I began reading it (five days ago) I got through the first few paragraphs and that gave me the motivation to call my insurance company about the pump-denial ordeal I’ve been going through – a call I’ve dreaded making, and therefore had been putting off. (After my last two-hour ordeal with them, I was given a phone number to call which led to a random-person’s voicemail “Hi, this is Bob! I’m not here right now, so leave a message. Bye!”)

    But this time, after getting transferred twice and disconnected once, I somehow navigated through the menu tree that gets me to the people who talk to doctors (not to patients), and the person on the other end told me that she’s “not allowed” to talk to me. But I think she sensed the desperation in my voice when I stated my case and pleaded “PLEASE don’t transfer me back to Member Services!!” that she stayed on the line and assured me she would connect me with somebody who could help. And she did, thankfully. I’m still nowhere near getting approval for the pump, but at least I achieved the baby-step of getting an answer to my question “What happened to the letter I sent in November?” (answer: it was lost).

    So forgive me for taking five days to read and respond to this post. The topic alone is enough to make my blood boil.

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