Trouble Getting that Insurance Claim Paid?

 

When the phone rang with the news, Kevin and I were sitting on our back porch eating dinner. Three hundred miles away, our son had gone up for a header in a college soccer game. Now he sat in the Emergency Room in Wilmington, NC with a concussion, a cracked orbital socket and a large dent in his brow bone.

“It looks like he’s been hit in the head with a ballpeen hammer,” his teammate said over the phone. My heart pounded. “But he’s OK,” he went on to reassure me. “He’s going back to Greensboro on the bus with us.”

Bram had to have surgery to pull the bone fragments out of the dent in his skull. Two titanium plates would be screwed in place across the hole. To accomplish this, the surgeon would slice his head from ear to ear and then peel his face down below his brow.

“Once the plates are in place,” the surgeon explained, “we’ll press his face back on, then staple his scalp back together.”

Our experience with the insurance company began smoothly enough. Aetna pre-authorized the entire procedure. Two days and 120 staples later, Bram was on the mend.

All went well except for the anesthesiology bill. It was more than $5,000, and Aetna declined to pay it. Since the company had pre-approved this, I knew there had to be some mistake. I phoned them.

“That doesn’t make sense,” the Aetna representative agreed. “We’ll run it back through.”

Another rejection letter followed. Reason: Bram was not a full-time student.

But he was. I obtained a letter from the registrar and mailed it to Aetna. “We’ll run it back through,” the rep said on the phone.

Another rejection letter. Reason: Bram was older than 23.

But he wasn’t. I sent Aetna a copy of Bram’s birth certificate. “We’ll run it back through.

Another rejection letter. Reason: Treatment not appropriate to the procedure.

“This is an anesthesia bill,” I said to the representative. “They had to peel his face down and screw plates in his skull, then staple his scalp back together from ear to ear—don’t you think that should require a little numbing?”

“We’ll run it back through,” came the response.

Another rejection letter. Reason: Incorrect code.

I put a call into the anesthesiologist’s insurance specialist. “That’s not right,” she told me, but I’ll look into it and try again.”

Another rejection letter. Incorrect code.

To avoid being whipsawed between the Aetna and the doctor, I organized a conference call between Aetna and the anesthesiologist. They appeared to have figured it out and the claim was resubmitted.

Rejection letter. “You can appeal this,” said the Aetna representative.

I put all my information together and wrote an official appeal letter.

Appeal denied.

I phoned Aetna to talk with yet another representative. “Why?” I asked. “You pre-authorized all of this.”

“That doesn’t mean a thing,” the rep told me, as he looked through the backlog of communications. “I don’t know why we’re not paying this,” he said. “But we’re not.”

60 days had gone by. I received a notice from a collection agency on behalf of the anesthesiologist. Now I was pissed. To Aetna, I was but a drop of water in a sea of claims. And each time I called, I got a different person. I wasn’t just being double-teamed; I was being kicked around endlessly from one Aetna team member to another.

What shocked me was that they were treating me not like a team member, but like an opponent. My employer had this great health care benefit, and still I was paying more than $600 per month to insure my family. Yet here I was, on the phone, on company time, trying to duke it out with the so-called provider. There were hundreds of them and just one of me.

I needed to make this a bigger problem for the company.  But how?

I went on line and looked up Aetna’s board of directors. An impressive group for sure, but with no contact information. But wait. Two of them were professors at major universities, one at Princeton and the other at Harvard. I went to the school websites and pulled their faculty email addresses.

Then I phoned Aetna again. “How many I help you?” asked the rep.

“I’d like to speak with your supervisor,” I said.

“But I may be able to assist you,” they said.

“No thank you.”

“Please hold.”

“How many I help you?” they asked.

“May I have your direct line? ” I asked.

“I don’t have one,” they replied.

“Then I’d like to speak with your supervisor,” I responded.

I did this until I got someone at Aetna that had a direct line. I was put into their voice mail.   No response.

I called the next day.   A man answered.

I explained my situation.

“How did you get my number?” he asked. He sounded suspicious. I explained the entire saga.

“So from now on, Dan,” I said, “until this is worked out, I’m coming straight to you.” . “And each time I talk to you,” I continued, “two of Aetna’s board of directors are getting an email from me, telling them what you are doing—or not doing— to help me.”

The problem was resolved in 24 hours.

It shouldn’t be this hard. I went through all the right steps. Did all the right things. But these companies do this routinely, in hopes that in the end, you’ll give up and just pay the bill yourself. And frankly, if our bill had been hundreds of dollars rather than thousands, I might have thrown in the towel.

My job at the time afforded me the luxury to sit at my desk, on hold for up to an hour, while I responded to my business emails and reviewed documents. What does a factory worker do? Or a schoolteacher?

This is just one illustration of why health care in America is broken. And as usual, the ones in need of the service are on the short end of the stick.

I believe the Affordable Care Act is a step in the right direction. I hope it’s the first step in many to come.

 

Thank you, Congress

When I left my job nearly three years ago, I left my health insurance benefit and went out on my own. “Are you crazy?” friends asked. A lot of folks, it seems, are afraid to leave their jobs for fear of losing their health insurance.

But I’d saved some money and had no glaring pre-existing conditions (or so I thought). Actually, I ended up paying a much higher premium than I would have otherwise because in the year before I left I’d seen a physical therapist for my Achilles tendonitis. Never mind the fact that I’m a runner and a hiker, therefore, in excellent cardiovascular shape. Also that year, I had a few sessions with a psychologist who gave me some stress management tools to help me with my father who had late-stage Alzheimer’s. In the eyes of the insurance company, this made me a much higher risk than someone who has not seen a psychologist.

Still, I wanted to pursue other endeavors while I was still young enough, and I was willing to use my savings to do it. I found a plan for my husband and me through Anthem. A year later, for reasons known only to them (they refused to elaborate for me), Anthem raised our premium by $100 per month. Yikes! So that I could afford to keep insurance coverage, I upped our deductible.

I’d gone on the Affordable Care Act (ACA) website in 2013 to see if I could obtain more affordable care. Late last year, the website was a mess. I had trouble getting on, and when I did, it seemed that we weren’t qualified. So I bagged it.

Then in January, my husband turned 65 and went on Medicare. Yippee! My insurance premium was more affordable than ever. A month later, I received a letter from Anthem saying that in July, they would cancel my existing policy and move me to a new one. The cost for the new policy would be more than twice my existing policy. I would go from paying $207 per month to $500 per month. Arggh!!

When I called Anthem to talk to someone about a more affordable policy, I was put on hold for two hours. Two hours of horrible guitar music interrupted in the same place every 30 seconds for a recording to tell me about grandfathered plans, which I don’t have. Finally I got someone, she took the same information I’d punched into the phone two hours earlier, and then she put me right back in the same hold loop. Finally I got a guy named Darrell in Houston, Texas. He told me that I should qualify for more assistance under the Affordable Care Act, and gave me a number to call.

I dialed the number and got put hold. But this time it felt different. The calming solo piano music made me feel good. Hopeful. A lady periodically thanked me for my patience and said I’d have their undivided attention shortly. My access to full health coverage was just a few minutes away. None of this gobbledy gook every 30 seconds about grandfathered plans, etc. It makes my blood pressure go up just remembering the Anthem hold button. This ACA music made me want to get my piano tuned and start practicing again. Maybe take lessons again. Really get good again. Anything was possible with this music.

The end of the story is that 20 minutes later I qualified for a significant tax credit and a reduction in the cost of a much better plan than the one I previously had. I signed up and it starts May 1st.

Initially I had some misgivings about accepting a subsidy. Then I came to my senses. Does Exxon Mobil have second thoughts about the billions in government subsidies it receives, even as it books record earnings for its shareholders? In my estimation, healthy Americans are even more important to this country.

But I think we’ve lost sight of something else that is really important to this country. The ability to move around in the job market. To pursue new endeavors, to try out new ideas. To start new businesses. I know brilliant entrepreneurial people who want to strike out on their own, with fabulous ideas about water management, renewable energy, and poverty abatement to name a few. People who couldn’t start up new businesses because they had pre-existing health conditions and couldn’t afford insurance if they left their jobs. The Affordable Care Act has the potential to change that. Yes, America. We can be great again.

I am healthy, and I have coverage under the Affordable Care Act. Thank you, Congress.