Category: Important Stuff

“Hello, Mr. Kauffman? This is (censored) from (my HMO). I just wanted to give you a call to let you know that we’ve resolved the issue with your daughter’s PCP (primary care physician). The claim submitted in October 2004 will be resolved, and you will not be responsible for any charges previously billed by the PCP.”

“You mean the 10/1, 10/2, 10/3, and 10/5 claims that I called about last week; I believe it was 11/28 of this year?”

“I don’t have the exact dates in front of me. I just thought I would give you a call on my break to let you know the issue has been resolved.”

“But you think ALL of the claims from October 2004 will be resolved? What about the other dates that I was billed for? Specifically, I’m referring to the claims denied for July 2002, March 2005 and May 2005?”

“Sir, you didn’t ask us to check on any dates besides the October 2004 claim.”

“Au contraire, mon fraire. Claim… S. That’s CLAIMS… as in plural. When I called on 11/28 I noticed, and was concerned, that the representative was focused on 10/04. I asked about four claims for October 2004; PLUS, on three separate occasions I clarified with your representative that the bill from the PCP listed three dates of service OTHER than October 2004 – specifically: July 2002, March 2005, and May 2005. I see that my efforts were in vain.”

“Sir, my break is over. I’ve got to get back to the phones.”

Click.

Talking to my insurance company on the phone has proven to be an excellent source of energy. Now I just have to find a constructive outlet for that energy.

Health insurance, billing departments, complaint resolution offices, and the automated phone answering system… horsemen of the apocalypse or God’s warning shot across the bow of today’s later day ark of bureaucracy and civilization?

All I know is that I don’t want to pay $800 for services that were supposed to be covered by my health insurance provider.

See if this sounds eerily familiar… your doctor sends you a bill for services your health insurance provider (HIP) denied coverage. You call your HIP and verify that these kinds of services are normally covered; but, they tell you your doctor never submitted the claim. You call your doctor and they tell you they did. You call back your HIP and they tell you your doctor didn’t. You call back your doctor for proof they submitted the claim, and they tell you it was submitted electronically… or in other words, fat chance getting your proof. You ask to speak to a supervisor, and they tell you she’ll call you back. A week later you get that call in the evening, at dinner time, at the precise moment your one year old son starts tossing a grand fit, whilst in the throes of hunger. The supervisor assures you she will have someone call your HIP and get things all straightened out… and that if she has any problems she’ll be back in touch. When she doesn’t get back in touch in two weeks, you become hopeful… until you get another bill in the mail for $800. So you call your HIP with the specifics of the bill (again), and they advise you they’ll forward the information to their complaint resolution office, who will respond in two weeks with their results.

My guess is there’s some research out there which suggests “two weeks” is the optimum answer to give to a complaining customer. It’s not enough time to seem like NEVER to the customer (like three months would), while still giving a fair chunk of time to actually do something; and, (most importantly) it gives the customer plenty of time to forget the complaint in the first place. What I’d like to know is if they actually intend to be DONE in two weeks, or if they’re giving a research based answer of placation. In either case, I’ve got my calendar marked. Maybe this is one case where business should run more like a government?

When conservatives say that government should be run more like a business, I hope to God they’re not referring to the insurance business.

Let me start by saying, the facts of the case I’m about to explain are mostly undisputed. The involved parties are: me, my wife, my daughter’s doctor, my daughter’s specialist, our insurance company, and our pharmacist. Here are the pertinent, undisputed facts:

1. My daughter has been correctly diagnosed with a condition that generally responds to medication.
2. This condition should be treated.
3. There is a relatively new medication that sometimes works when other’s do not.
4. This medication is not normally covered by insurance, unless the other alternatives have been tried first.
5. My daughter has taken all of the available, relatively cheap, alternative medications; which did not work.
6. My daughter’s doctor has submitted the correct documentation in order for insurance to approve the medication.
7. My daughter’s doctor wrote the prescription one month ago, and we attempted to get it filled immediately.
8. Our pharmacy is in possession of a properly completed, hand written prescription from our daughter’s physician.
9. Insurance has approved the prescription.
10. We have attempted to pick up the prescription more than once, AFTER insurance “approved” the prescription.
11. We still have not been able to actually purchase the medication.

That last one bears repeating: we still have not been able to purchase the medication. Why on earth not? Now we get into the disputed facts:

1. Insurance claimed that Beth’s doctor did not send them anything on a timely basis. In fact, Beth’s doctor provided us with FOUR fax transmittal receipts, showing they did submit the documents on four different occasions – to the fax number provided by the insurance company. The first fax was less than one week after the doctor wrote the original prescription (immediately after we learned it would be necessary – based on my hunch, that insurance would not cover the script without some extra effort). The last fax was found right after Cheryl lost her temper with the unsuspecting insurance customer service rep. I find it amazing that force of will can affect the physical world in such a manner. I was taught in high school that matter could be neither created nor destroyed – but apparently it can be teleported with sufficient emotion.

“Nope, we still haven’t received it.” **ANGRY RESPONSE CENSORED** “Oh, here it is.”

2. The pharmacy did not submit the insurance claim correctly. In fact, in a rare display of dedication from a low wage, pharmacy tech, this author watched the pharmacy call the insurance company on two separate occasions – so that the insurance company could walk them through the process to make sure it was submitted correctly.
3. Beth’s doctor is not authorized to write prescriptions that are covered by our insurance company. In fact, we got prior approval to see the doctor – which we verified with our insurance company on the morning of our appointment. Further, insurance had approved two prior prescriptions written by this same doctor (less than three months ago). And finally, I called them on my cell phone from the pharmacy lobby – and they assured me the prescription had been approved. Why would they tell me the prescription was approved on the phone – as written by this doctor, and then deny it when the pharmacy submits the claim? How, in the name of all that is holy and good in this world, can my daughter’s prescription be approved by the insurance company, but the pharmacy claim be denied? Is it approved or not? It seems to be a black and white issue, a boolean variable, one or the other, MAKE A DAMN DECISION AND STICK WITH IT, #@$ !@%& *&!!

Here’s the score, as it stands today: one month, 25 phone calls, two trips to the pharmacy, two hours in the pharmacy lobby, 60 cellular minutes (30 of those cellular minutes spent in said lobby – the other 30 spent long distance from New Hampshire), zero prescriptions filled, AND TWO IRRITATED PARENTS.

I am pleased to announce that this month is the benefits open enrollment period for state employees. We have until October 15 to make a change to our chosen health insurance provider.