Mnemosyne has been on fire in comments regarding what to do when you think an insurance company is screwing you over:
Assuming he hasn’t been able to appeal successfully to his insurance company, I’ve been strongly encouraging people to file complaints with their local insurance regulators and with HHS. …It’s really, really important to let the state and federal regulators know whenever an insurance company does something hinky, because if consumers don’t report it, they won’t know….
I say, complain anyway. Make them explain to the state and to the federal government that it was someone else’s fault while providing boatloads of documentation. My husband works in healthcare and whenever a state regulator shows up, it’s a really big deal.
Am I advocating that you be a nuisance and make the state investigate things that are probably legal on paper just to annoy the insurance company? Yep!
She is exactly right. If you are unhappy with your insurance company complain. If the front line staff can’t satisfy you, complain some more. If the management staff can’t satisfy you, complain to the c-level while CC’ing your complaint to the state regulator, the local newspaper, local competitors and the effectively annoying investigative reporter. Even if what the insurance company is doing is legal, at that point, the Andy Rooney rule comes into play — C level execs don’t want to be chased down the hallway by Andy Rooney and the 60 Minutes camera crew, so a solution will often be found.
A short story here — as part of the Mayhew Insurance Exchange offerings, we offer a very narrow network product. It is fundamentally designed to keep people away from an expensive chain of hospitals. All of the marketing material has 72 point warnings saying that we won’t cover non-emergency services at That National Hospital Chain. Someone bought that product and then three weeks later had an elective surgery at That National Hosptial Chain. The individual in question had received a denial of authorization and a follow-up phone call to say that the surgery would be authorized at the other three hospitals the surgeon had privileges at, but not at Hospital X. The bill was denied as out of network, and the person started to complain that we engaged in unfair and deceptive advertising.
The complaint escalated to the C-level and local reporters within a week, and there was a massive meeting to determine if we unfairly screwed the person over. Legal was of the opinion that we were in the clear, and marketing/PR ran the calculation that is was cheaper for us to pay the claim then to take the hit from several thousand pissed off words in the local paper. We paid the claim as if the member was in network.
Complaining works
mtiffany
If they had the power/authority to solve real problems, they wouldn’t be front-line staff.
WereBear
I think liberals like regulations for the additional reason that we don’t want to whine and complain and make a huge fuss just to get something done.
Since so much of what conservatives want is stupid, they are used to it.
Regarding the example shown here: this jerk just took a decision away from someone who followed the rules and needs the exception. We shouldn’t have to threaten business to follow the rules. That’s what we pay taxes for.
But if you gotta complain, sure. Do it.
Phylllis
I think that’s actually the Mike Wallace rule, but other than that, spot-on.
Richard Mayhew
@Phylllis: yeah, but the visual image of Andy Rooney doing the chasing is funnier to me.
LittlePig
I remember while working for a Medicare B carrier that the most dreaded words were “Office Of The Inspector General”. An OIG request made ’em stand up and heave to, and how.
LittlePig
And while working for a power utility those same words were “Public Service Commission”, and they caused the same furor. Like they say in magic, knowing the right Name to Name really does give true power.
ulee
I remember the good old days. I have worked in social services for a couple of decades. The pay isn’t good but the medical plans were always great. It was a twenty dollar co-pay on doctor visits. I’m still in social services and I have a three thousand dollar responsibility before the insurance company (Anthem) starts to pay up. Result. I don’t go to the doctor.
GHayduke (formerly lojasmo)
My claim for detox was denied because of failure to pre-authorize. My chem dep councillor told me he was going to call to pre-authorize, so I’m going to raise hell.
ETA: in the fifteen years I’ve had this insurance, I have never ONCE had to pre-authorize prior to this.
ulee
I know I’m being ripped off but I keep my insurance in case of catastrophic illness or injury. As far as day to day coverage, they’re useless.
Schlemizel
@GHayduke (formerly lojasmo):
Part of that may be the large number of charlatans in the rehab field. Part of it is the continued belief that dependency problems, like mental health issues are not real issues that need to be treated by professionals. The providers are still operating on an early 20th century belief that those sorts of things are moral failings not disease so “cheer the fuck up, stop abusing and fly right mister” is the best course; which you can of course get for free.
Rob in CT
It’s a good idea for any given person, obviously. Even if the insurer did nothing wrong, the squeaky wheel tends to get oil.
However, when I read your story about the out-of-network elective surgery, I couldn’t help but think “great, there goes any cost control.” What happened there was not a patient being screwed. What happened is a patient got something for which they did not pay premium (result: that extra cost gets spread to other patients).
Maybe this is the insurance coverage analyst in me, but it seems to me that paying that claim was not the right answer for us all. It was good for the patient, and less bad for the insurance company than the alternative, I get that. I’ve been through this scenario before as well, many times. Usually there’s enough question as to the underlying facts to make it palatable (when you deal with long-tail environmental claims, you’re often arguing about stuff that happened ~40 years ago. Certainty about the facts is unlikely). There’s also often caselaw that makes the seemingly insane perfectly normal (I’m looking at YOU, Indiana), and you get used to it… but I digress.
TL/DL: in this specific scenario, the result was a socialization of the costs of an elective surgery that a patient knew or should have known wasn’t covered in-network. Most disputes probably aren’t like this (I hope), so I’m complaining about a case at the margins.
rikyrah
The story of Nat King Cole and his racist neighbours
Nat King Cole, the first black American TV star and a friend of President John Kennedy, conquered hearts and minds across the world with a string of hits in the Forties and Fifties.
But behind the singer’s ever-present smile lay sadness at a racist campaign of terror that he and his family suffered at the hands of his wealthy white neighbours on Hollywood’s doorstep.
The full extent of the hostility endured by the musician in the exclusive Los Angeles neighbourhood of Hancock Park has now been revealed in a new documentary.
The jazz pianist and singer had already achieved star status with his King Cole Trio when he decided to move in 1948 to the well-to-do suburb, which boasts Howard Hughes, Katharine Hepburn and Mae West among its former residents.
But Cole and his family were breaking new ground as the first black people to live there. Their arrival sparked a storm of protest, beginning with a legal battle by the Hancock Park Property Owners Association to try to prevent him from buying the house. When that did not work, the association tried to buy the house from the star. And months of abuse followed, in which his dog was poisoned and racial insults burnt into his lawn.
http://www.independent.co.uk/arts-entertainment/music/news/the-story-of-nat-king-cole-and-his-racist-neighbours-9391316.html
Violet
Does anyone know about appealing anything to Medicare? How about any of the Medicare supplemental insurance offerings?
I’m in a terrible situation and don’t know what to do. My dad had foot surgery several weeks ago. He’s recovering but it’s slow and he’s still on crutches. Meanwhile, my mom fell and broke her arm. It required surgery. She had that last week, is recovering, but can’t get herself out of bed and still has some fall-related leg pain that we can’t find the source of (CT scans of hip and pelvis are thankfully negative). In the middle of that, my dad came down with shingles.
So now my dad’s doctor won’t allow my mom to come back to the apartment in the retirement community where they live because she (mom) was in the hospital and exposed to hospital bugs. Also, the strain of having my mom around, who can’t quite take care of herself yet, would be too much for him. So dad’s doctor has said mom can’t come back until she (the doctor) clears it.
I had to scramble to get mom into the nursing section of the retirement community but it’s ridiculously expensive because Medicare won’t pay for it since she wasn’t in the hospital three nights.
Is there ANY way to appeal this lack of coverage to anyone? I don’t even know where to start. My mom needs help getting out of bed. My dad can’t have anyone in the apartment due to infection risk and he certainly can’t have my mom there since he would want to help her.
It’s really going to be short term until dad is over shingles and mom has learned to cope with the arm a bit better. It’s probably about two weeks, maybe up to three. I can’t see it going more than that.
I don’t even know where to start. How do I appeal Medicare?
Joy
The same thing happened to my sister except that it was the doctor’s office who confirmed that her surgery was covered under her insurance plan. To her surprise, after the surgery, they claimed it wasn’t covered. Between the hospital, the doctor’s office and my sister, they finally agreed to pay the $17,000 surgery bill much to her relief. So yes, complain and don’t give up. The conversations weren’t recorded by the doctor’s office but names were noted. It was the insurance company who went over the tapes and discovered that they had made the mistake.
Tata
I’m a state worker. Our state dental plan has a very limited number of participating dentists and the one in my town that accepted our insurance retired, leaving the closest dental practice three miles away. I don’t like that practice. Every time I walk in there, they extract $1100 from my bank account. Anyway, I have complained several times that they should find more dentists. The last representative I spoke with did everything but blink his eyes in Morse Code that it was policy on the part of the insurance company to let the number of providers dwindle. What do I do now?
a hip hop artist from Idaho (fka Bella Q)
@Rob in CT: This is the point that’s most important to me. Mayhew got played for a PR save. While I get the coat analysis, I find that it unfairly rewards an intentional (or near as makes no difference) flouting of the rules. What’s the point of having a narrow network if it just gets expanded when someone who ignored the rules – with plenty of warning that they were doing so – has an out of network claim paid as in network?
Derrr
Only if you are hetero normative or have some sort of hook that causes an empathetic or sympathetic response in others. If you aren’t a person who gets sympathetic or empathetic responses, none of that sort of shaming culture will ever work in your favor. all of the tools of social justice will only further alienate you. No one will care. Get your mind right and get ready to spend the rest of your life in prison. Because one day a motherfelcher actually is going to tell you they would have given a shit about you if only they had known.
Another Holocene Human
So I spilled coffee & grounds from the filter in my breakfast and then I dropped my toast butter side down.
Oh, you said complain to the health insurance company. We need health advocates. I don’t have the energy by the time they’ve “lost” my paperwork and deep-sixed my claim.
This is why libertarianism is and must be the religion of the basement dwellers. Because they don’t have jobs or responsibilities they can spend hours comparing one brand of solid state storage to another. But people WITH FUCKING LIVES don’t have time for that shit and without regulations with teeth and regulatory bodies and ya know NANNY STATE our lives spin into disarray and you get third world conditions like the Deep South. Funny, funny, some of the most high tech productive states have serious state level regulation going on, California and Massachusetts. Hmm hmm hmm. New York, also, too.
Think about all the productivity costs Floriduhhhh incurs by not bothering to properly inspect restaurants and fishmongers and allowing so many people to get sick from shellfish and fish annually. Mass has a crew of inspectors that force firms to keep filter feeders in clean water for 24 hours and has actually banned some fish because they couldn’t find a reliable way to procure and store to keep it free of toxic bacteria. It’s amazing the misconceptions North and South have of each other. If somebody up north showed up to work the way they show up and don’t in the south, they’d be out of a fucking job. And if they did as shitty of work they’d have someone in their face telling them so. And if they reacted to the “insult” the way they do in the south the police would be called and they’d be off the premises in handcuffs.
Yup, I’m fulla bile today. Fuck everything.
Phylllis
@Richard Mayhew: Was to me too, actually.
Another Holocene Human
@ulee: Anthem is evil. Kind of fitting Keith Giffen made anthem the name of a fascist paramilitary organization wrapped in the flag.
(Huh, didn’t realize it only appeared in a few issues because that Anthem storyline scared the sh#t out of me.)
PS: Keith Giffen created LOBO. And he is awesome.
Mnemosyne (iPad Mini)
@Tata: @WereBear:
FWIW, I’m thinking of all of this complaining as a way to help fix the early version of Obamacare. A lot of insurance companies are trying to see what they can get away with in this brave new world, and we as consumers need to make sure we let regulators know if the insurance company is doing something hinky.
So what I’m advocating is that if your insurance company seems to be trying to screw you (the original poster’s son was told he was going to have to pay the whole out of pocket max as his portion of a minor surgery), speak up so your state and the Feds know what the insurance company is up to.
Shorter me: if your insurance company says they can’t do something because of “Obamacare regulations,” they’re probably lying, so report them.
Another Holocene Human
@Tata: Depends on the state of your teeth. I dumped my municipal employer’s shitty dental plan and just pay directly to a dentist who was recommended by a long-time resident of the area. The guy just really loves dentistry and the prices are very, very fair. His hygienists don’t hurt my mouth, which makes me actually come to get my cleanings. I had a bad experience that had kept me away for a few years.
At one point I even asked him about orthodontics because I have a small jaw and he told me quite confidently that I had very healthy teeth and I didn’t need to alter them. Some dentists in town make all their money convincing idiots to get ceramic teeth or other shit like that.
You have to find out what the practices charge cash. There are dentists who just want to rack up bills to make themselves money and they actually do YOU a big disservice. Avoid them like the plague.
NotMax
@Another Holocene Human
Small correction:
Keith Giffen co-created Lobo, along with writer Roger Slifer.
Villago Delenda Est
@Another Holocene Human: But it’s righteous.
Rail onward!
Tommy
I fought an insurance company for a year, No winning. Google them. Fortis and lawsuit.
I had a good lawyer. He told me he would be less to just pay my medical bills then engage him to fight.
Villago Delenda Est
@Another Holocene Human:
OK, you lost the wingnuts with the very first word in that sentence.
These people have no critical thinking skills. No understanding of cause and effect. No ability to comprehend nuance.
At all.
Ed
Seems like this person was either really stupid or really douche-y. Since it is elective surgery the trird option ( that they were too sick to think straight ) is off the table. But why did the Doctor AND Hospital allow this person to get the operation at Expensive General?? That seems criminal to me.
japa21
I understand the point of Mayhew insurance paying that claim, but that doesn’t mean I like it. It does reward bad behavior. I would imagine, and hope, that in paying the claim they are making sure the patient knows that they handled the original claim correctly and that it was a courtesy and will not happen again.
But yes, complaining works. Sometimes just knowing the state insurance commissioner is going to be involved will be enough. Most isnurance companies don’t want the hassle, and resolving the claim is the less expensive way to go.
At other times, going very public is the way to go. Several years ago CIGNA was in a fight overing covering experimental treatment for a young woman who had tried several different forms of treatment to no avail. CIGNA, like many insurance companies, will not cover experimental treatments until they have been shown to have positive results. Of course, the definition of positive results is up to the insurance company.
In this case, the parents of the patient went very public and there were demonstrations outside CIGNA’s corproate office. Finally, CIGNA sent them a letter authorizing the treatment. I believe it arrived the day after the patient died (if not it was just before).
Mnemosyne
Also, too, note that I’m advocating that people file a report with state and
localfederal regulators, not necessarily file a lawsuit. When insurance companies were sending letters to people telling them that their policies were going to be canceled and “Obamacare” required that they be signed up for a platinum plan, everyone who received one of those letters should have filed a complaint with their state insurance regulator and with HHS.This is especially for people in smaller, blue-ish states like New Mexico and Colorado, where you kinda are getting screwed by the lack of competition. Complaints could help convince your state governments that they’ve got a problem on their hands that needs to be fixed.
Avery Greynold
I’m with that K-word chain of hospitals/doctors that doesn’t have paperwork. Before you switch, be aware that while they don’t deny payment, their frontline medical providers can be barriers to specialists. Here too, the passive can suffer.
rikyrah
where’s the new OPEN THREAD
rikyrah
where’s the new OPEN THREAD
David in NY
I think (hope) Richard’s example is atypical, and my experience is more the rule. My son was passed out after profusely vomiting blood in the floor in a hall of a Harvard classroom building. Was taken three or four blocks to a hospital by ambulance. He was OK after a few days of hospitalization (kind of well-known rupture of esophagus-stomach junction). The ambulance billed us $1500 and the insurance company denied it. I called and complained. The front-line person said, “Wait a minute, I’ll talk to a supervisor,” came back, and said, essentially, “Nevermind.”
I have always assumed they were just hoping I wouldn’t contest it and knew they were wrong. And I’ve always assumed that this is the most common situation (aside from having been misinformed by the doctor or insurance co. about the availability of coverage in an elective situation). That’s why I’d complain — I’d suspect they were just trying to dodge the responsibility.
BAtFFP
A good friend recently discovered that, without any fanfare, her insurance had recently put in a one sentence exclusion clause saying they would not cover work-related injuries. Which is all fine and good and makes a certain amount of sense unless one happens to run one’s own small business and purchases an individual insurance policy. In WA State these workers also apparently supposed to buy need worker’s comp to cover potential injuries.
She had no idea individual insurance could even exclude this, and had never heard a single warning about it — not from the WA State exchange website (which helpfully tells the self-employed they have buy individual insurance), not from the various small business groups she belongs to, NOTHING. She and her husband did all their due diligence except very carefully read the exclusions. It’s at the end, past nose jobs.
Anyway, the upshot of not noticing that one very small, unannounced addition to the exclusions means that the regional trauma hospital will be eating a $300,000+ hospital bill for the 3 weeks her husband spent there after falling off a ladder while working. Andy Rooney would love it.
StringOnAStick
@Another Holocene Human: I worked as a dental hygienist for a temporary services firm for 5 years, and I have to say that while I think most dental offices are legit, some are very definitely very into up-selling and/or have obscene prices. Ask what the prices are, and if you feel like you are being pushed to buy extra services above and beyond what is typical, find a new dental office. The chains tend to be either barely passable levels of care, or are working the system as hard as they can to increase their billing productivity; not all of their offices are that way but I have seen some truly obscene treatment plans that were in no way legit, like the root canal therapy and crown for a cavity that wasn’t even halfway through the enamel – serious, expensive over treatment.
Most dentists are OK, but there is a subset out there that subscribes to the dental magazines that are all about increasing profits and sell, sell, sell as the way to financial freedom for the DDS. Funny how most offices I have seen like this don’t pay their employees well but the DDS is making bank while dealing with nearly constant staff turnover (constant staff turnover is also a hint about whether or not you should stay with a practice). Some have gotten smarter and are either not obviously part of a chain, or they give the staff a cut of the profits so everyone is pushing hard for more $.
Like the place I worked where my patient told me she’d been laid off for 6 months but knew it was important to keep her 6 month cleanings. When I told the DDS exactly what she’d told me, he proceeded to try to sell her on $5,000 worth of cosmetic dentistry that she really didn’t need, especially when she was unemployed with no prospects on the horizon. No empathy, just the need to vacuum out every patient’s wallet as effectively as possible. Also, the only thing to read in the waiting room was a bible.
catpal
What can you tell me about Health insurance companies that pay $$$$ Millions for erroneous or fraudulent claims.
I recently found out that my insurer does Not send out EOBs for every claim submitted — I only received an EOB if there was a patient liability. After requesting All EOBs, I found 2 that were erroneous or fraudulent payments made by my insurer to a provider I don’t know.
So company policy of NOT sending out all EOBs means that Insurance company is probably losing $$$ millions- then raising our premiums. Who to complain to about that?
Eric U.
@David in NY: this has been my experience, they deny and then deny on resubmittal because it was previously submitted. Then when challenged they pay. I suspect the people that do that don’t last that long, it’s almost surely considered bad practice by insurance companies. My wife is the sort of person that might pay to avoid unpleasantness.
@StringOnAStick: my dental practice accepts our insurance, one of the few in town that do. They try to up-sell all the time. The least competent dentist wants to do oral surgery and endodontics, it’s just nuts. She ends up with the people on our insurance, probably because people refuse to see her. I am incredibly happy with the crowns that the dentists at this practice have put in, which is why I fired my last dentist. But I’m at my limit and shopping for new dentists because of these issues. They wanted $500 to dna test the bacteria in my gums. I’m not that interested in their dna, to be perfectly honest
Elizabeth
When I began working for a MediCal access line, I suggested to my coworkers that consumers who were having real problems with institutional providers could report their difficulties to the state Insurance Commissioner’s consumer complaint hotline. No one I worked with even knew about its existence, although they thought it was a great idea. I look up the number for callers on a regular basis. Often just mentioning the commissioner’s name is a potent signal that one knows one’s rights.
Heliopause
Awesome. I can look forward to spending the last few decades of my life on the phone complaining. God bless America.
WereBear
Dentists can be ridiculously expensive, but so can the consequences of NOT seeing one.
Still stupid they & vision not covered. The ol’ “toothless blind soothsayer” jobs just aren’t as popular as they used to be.
pseudonymous in nc
@japa21:
Yeah, if you decide that you want to go to the Miracle Whip Clinic in spite of being told that it ain’t on the list, then call the fucking waahmbulance. The sense of entitlement at the top contributes to people having to suffer at the bottom.
Glocksman
It may not have the same legal authority as ‘OIG’ does, but if you’re on a group policy with a large employer who gives a damn, having your employer’s HR department call the insurance company can get results.
They may not listen to a single individual, but when talking to someone who represents 1500 policyholders at a single throw they listen.
Glocksman
@Elizabeth:
That’s assuming you live in a state where the Commissioner cares about people.
Living here in Indiana I cannot make that assumption.
Mnemosyne
@Glocksman:
That’s why I was saying you should duplicate the complaint to the federal HHS — even if the state wants to ignore it, the feds can pressure them or even do their own investigation. And if you think people run around like frantic ants when a state inspector shows up, see what they do when a federal government inspector shows up.
C.S.
@mtiffany:
Or, as my mom has always said: Don’t take ‘no’ from someone who can’t say ‘yes.’
texdoc
@a hip hop artist from Idaho (fka Bella Q): In this scenario, where the insurance company pays “in-network” rates for a surgery at an out-of-network hospital, the insurer is out no more money than they would have been had the insured person chosen a hospital in network (they would have saved some money had they refused all payment). That does not mean, however, that the out-of-network hospital can’t bill the patient for the difference between what they charge and what Mayhew Insurance paid. (That happened to me once, with an anesthesiologist who was not on my insurance, even though the hospital and the surgeon were–particularly annoying, since all I needed was a local. My insurance paid the in-network rate, the anesthesiologist kept billing me for the difference, and I finally complained to the hospital. Most galling was the fact that you don’t pick your anesthesiologist before minor surgery, you just get the next one in line. Who thinks to ask at that point–are you on insurance X?