Tagged: how to handle a health insurance claim denial

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.