I just can't join in on the Tea Party debate this morning, guys. I'm in a Boss Battle, as my kids would call it, with our health insurance company to cover therapy for Ian. They owe us a couple thousand dollars and they just won't pay it.
This morning, I talked to Gloria at Empire Blue Cross Blue Shield yet again. I've probably called about 40 times over the past six months. They owe us a measly $500 or so for therapy for the fall. But they keep throwing obstacles in my path. Yesterday, I had to drive 30 minutes away to the neurologist's office with both kids after school to sign some release. Today, they told me that they don't need it anyway.
Last spring, they told us they were going to pay for it, but the check hadn't been cut for some reason. They said they would call me back to let me know what the status was. They never called back. I called back a few weeks later, working my way through the phone tree to find out that it hadn't been approved. They wanted still more documentation.
I've resubmitted the paperwork at least five times. After three tries, the therapist finally figured out the top secret codes to put on the forms. I have letters from his neurologist. I even had the therapist give us a copy of his diploma to submit.
I've only been denied two times from the new insurance company for the spring therapy. 38 phone calls left to go.
The school says that he should have additional therapy after school, but they won't pay for it. The doctor says that he'll really benefit from more therapy. The literature says he needs therapy. But nobody will pay for it.
Yeah, I cried.
Apt. 11d 
Man this sucks, Laura. I wish it would stop, for you guys and for everyone.
The schools won’t offer my friend’s daughter her therapies because the budget was slashed, so her daughter leaves school early to get them. Now the school is complaining that her daughter is missing too many class hours. They pay out-of-pocket, because they have the money, but what about all the other kids in the district?
Penny wise, pound foolish, is what those budget cuts were.
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So a letter from a lawyer always helps. It doesn’t have to be a lawyer you plan to use any old lawyer will do. NB: you probably can’t sue them because you’ve agreed to arbitration and the arbitration will cost you money but you can only get the reimbursement costs back, not your lawyers fees and such. However, you might have grounds for starting a class action suit if you think you can show that they are systematically denying claims they know are legitimate or creating bullshit run-around stuff in the hopes that people will drop the claims. Some folks have been trying this strategy in various states and the cases are moving forward. Whistle-blowers help here (and they can get a big chunk of money if gvt. $s are involved) so keep an ear out for anybody who might supply evidence.
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I’m in the odd boat that I think that insurance companies sometimes have to deny claims (I’m probably the only one who thinks that it might be a good thing if mammograms weren’t paid for by insurance before the age of 50). But I also agree with Dave that if you’re being given the run around, rather than a policy you disagree with, and it sounds like you are, it’s a battle worth fighting for the cause (even if you could just pay).
In your circumstance, I always opt out of doing battles in favor of just paying for things myself, but then feel a little bit guilty, because I know that I’m letting the evil stay in place by not fighting for my rights. No pressure to fight, of course, but perhaps a pat on the back for doing what you think is right?
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I wish you luck. Also, I’m now going to refer to every bureaucratic hassle where I talk to somebody’s supervisor as a “boss battle.” Thinking of it as a video game may help.
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Yeah. I have to make a decision whether or not this is the best use of my time. The principle v. the headache/tears/time.
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“Thinking of it as a video game may help.”
Meaning, each time you go up to a new level of supervisor, it means you’ve cracked a new level?
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I assumed “boss battle” was already a video game reference. You’ve beaten the minions and now the big guy is there in front of the princess or whatever.
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I had to fight with an insurance company to pay for the anesthetic for my emergency c-section. Someone actually told me that the company didn’t pay for anesthetic injections. It took me 3 months of calling and all my medical billing expertise to get it done (I used to be in medical billing).
That said — Laura — can you tell if this is a coding issue or a coverage issue? I guess this is through Steve’s work, right? I’m not a rocket scientist about this, but I have some familiarity with the terminology. Let’s get coffee. Bring the bills/paperwork.
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Do you think it’s a tactic on the company’s part, to delay payment, or could it be ascribed to inept employees?
I have a theory that any system which grows too complex will not function well, because anyone smart enough to understand and apply all the procedures won’t be working in customer service. They’ll be off splitting the atom or something.
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It’s willful ineptitude. They don’t want to pay for therapy for autistic children, but New Jersey law says they have to, so they never outright deny a claim. They just say that you need more documentation. After they lose your file. And wait two months. The latest hurdle is that they want every scrap of paper in his medical files with the pediatrician and the neurologist.
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I’m sorry. I hate them. Fuckers.
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An insurance company once claimed that my son’s enteral formula, given to him via stomach tube, his only form of nourishment, was not medically necessary. This is definitely a tactic: they test to see if they can get away with whatever they can. If they said they would pay for it and haven’t there may be grounds for you to act aggressively. Read the policy. Tell them you are getting a lawyer (that worked for me). They are searching for their own profits and they will take it from you children….
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I am so sorry Laura. That is incredibly frustrating. I would go off on a rant about American insurance companies but in truth I’m not sure the Canadian system does much better for kids with special needs, or even with therapy in general. It’s difficult to build capacity in the system to meet the need, and when you don’t, well – it’s a vulnerable group that doesn’t always hold a lot of sway.
At least here I know I can lobby for my friends facing those issues. Anything that can be done for you?
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Could Steve’s company issue a short-sell recommendation until your issue gets settled? Or hell, just short them for a while and let the market wonder what they are missing. Know anybody at the trading desk?
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has your husband asked if the people in HR have policy admin? We had issues with the girls insurance for ages and paid 1000s out of pocket. But once this middle man got involved and called it was paid for immediately.
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Also, the Infallible Wikipedia(tm) tells me that many BCBS organizations are entitled to “special tax benefits” under section 501(m). Why not slip an amendment into the next defense appropriations bill? Know anybody on the Hill?
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These proposed remedies are strictly pour encourager les autres, of course.
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I second jenny’s suggestion — there might be an ombudsman of some sort who can help you.
Also this might be a situation where a lawyer can help. I get the impression that your rights may have changed with the new law in NJ (which took effect in February, or whenever you policy was updated. If so. The company may not actually know the rules that apply.
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You have my sympathies. Our insurance has been good, here, and we’re getting therapies covered through the schools and my insurance plan at work but it’s still a lot of work to document the request for service. If I had to document at that level for reimbursements? I’d be crying, too.
Instead, I’ll offer to zerg with you if that’ll help!
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So sorry! I agree with Jenny. The folks in HR should be able to help navigate this mess.
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@bj sure companies can deny claims, but that’s not what’s going on here. They are systematically not denying the claim but not paying it either hoping that Laura just gives up. Since most people won’t pursue a claim for small amounts (and for folks with health insurance, while 500 ain’t chump change, it’s not a choice between that and food) they just cough up eventually and the company gets fat. If you agree to go to arbitration (which you probably did in advance when you signed up for health insurace), you’ll probably need a lawyer (somebody like my brother) who can walk you through exactly what your rights are. Even if you win, you only get what you were entitled for. You’re still out your lawyer money.
File a class action and take these mothers down.
And the best way to win a boss battle against the Level 7 Pencil Head is to use the seltzer bottle, preferably with a gag boost. Did I mention I took over my son’s extra Toontown account this summer?
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I wish I had something constructive to offer. But all I have is Fuck those fucking d-bags. They are trying to wear you down; stay strong.
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Thanks, guys, for the support. I will call my husband’s HR today to complain. I couldn’t do it yesterday, because I was so exhausted with all of this.
Our problems are minor compared to other friends I know. Some have multiple kids on the spectrum and put out ten of thousands of dollars in unreimbursed money on therapy.
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How absolutely awful. I’m so sorry.
There should be some kind of online support network for this, a site where you could go and anonymously discuss a particular company’s reimbursement practices and share whatever you learn about billing codes, strategies (like bringing in an HR person), etc.
My mom dealt with this with my grandmother’s health issues and I suggested back then that she become some kind of ombudsman for the elderly who have to work with insurance companies. She learned so much and it would have been good for that knowledge to benefit someone else.
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File a class action and take these mothers down.
The worst part is that somebody at the company sat down and figured out that a class action suit was likely to cost them less money than what they saved by deny, delay, stall, and make people go back to square one.
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The worst part is that somebody at the company sat down and figured out that a class action suit was likely to cost them less
How very strange that companies like laws that cap liability to set dollar amounts.
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“The worst part is that somebody at the company sat down and figured out that a class action suit was likely to cost them less”
“How very strange that companies like laws that cap liability to set dollar amounts.”
The NJ law caps the “autism” benefits to $36,000 according to the FAQ documents.
And, I absolutely detest the delay/distract/demand method of denying benefits, so I hope Laura has the stomach to fight back. I understand that they benefit from the mess. The only real question is if the mess is policy or bureaucratically driven. If bureaucratic, it’s possible that it can be fixed with HR personnel/the right paperwork.
(but, regardless of what the motivation is, it’s clear that it benefits them and not you, and that asymmetry is a deep problem).
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You’ve probably considered this option already, but if not, have you tried this doc? Available at this link?
Even if the insurance company is within the letter (but maybe not the spirit) of their obligations to keep requesting additional docs in the specific case, sometimes getting a file opened at the state’s insurance regulatory agency, and notification of such sent along to the insurance company, in regards to your claims, greases the wheels. I’ve seen the Department of Insurance (in another state) get pretty quick results.
Appeal form sez:
“You also MAY submit a Health Care Provider Application to Appeal a Claims Determination IF the Carrier’s determination:
> Indicated the Carrier required additional documentation to support the claim and you believe that the required information is inconsistent with the Carrier’s stated claims handling policies and procedures, or is not relevant to the claim
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