Insurance hell
 

AAAAARRRGGGHHHHH!!!!! I HATE BUFFOONS!!!!!

My wife went in for knee surgery on 11-5-08. Our PPO provider is Blue Cross Blue Shield.

Neither we nor the care provider has received payment. My wife finally gave up in disgust trying to get this resolved. I've taken over the reigns and have been keeping careful notes on the assumption we will have to sue.

Apparently they think a check was issued. Some in their organization say that it was intercepted before it was mailed, some say it was mailed but hasn't been cashed. Still others say there is an open investigation to determine whether or not it has been cashed.

Regardless, this claim is over 6 months old. I can't imagine how surgery centers stay in business if this is the kind of malarkey they have to deal with.

I've asked to speak with a supervisor, but they can't just hand over the phone apparently. I will be contacted by a supervisor in the next 24-48 hours (not holding my breath). I have the phone number to the legal department, but not sure if I should expect much joy there. I'm thinking I might at least explain what has transpired, and they may realize they could have a legal problem on their hands if this isn't handled post haste and take care of it themselves.

So, my question to those in the know, is how do I bring pressure to bear? Clearly calling multiple times is not having an effect. I want to request all the notes they have on this claim/case, and have an address to submit a written request. What other things should I be requesting? Should I write my congressman?

Get the local news guy on them.

Not sure which local news guys to use - I'm in San Diego, the office I'm dealing with is in Maryland.

Maybe a call to my local news would generate some interest - I'll give it a shot.

Just say the magic words insurance companies' hate to hear: "My lawyer is suggesting a bad faith refusal to pay a claim lawsuit."

Call your States Attorney Generals Office

I've left a message with their legal department to give me a call - I think it was lunch time when I called. I'll explain what I've been thru, and mention I've discussed this with an attorney, and will definitely toss out this nugget.

Insurance companies make a fortune "on the float".

They delay payments for months and months. It's a very profitable game. Sometimes they claim that the doctor hasn't submitted the proper paperwork, or claim that the patient's insurance has lapsed, or state that they have already paid the claim. The excuse is never valid, but the delay in payment is very profitable.

This kind of thing makes me really angry. I'm not the sort to sue just because I can pick up extra scratch, but the thought that Diana's surgeon (a REALLY nice guy) and the surgery center bear the brunt of this kind of BS just gets me boiling.

Our health providers make their money by:

• Sacrifice lots of time and money for an advanced medical education
• Pay a fortune in overhead, salary, and malpractice insurance
• Actually perform surgery that benefits people who need it

My effin insurance company makes their money by:

• Stiffing those mentioned above for as long as they can get away with it

I had a similar situation two weeks ago. I ended up asking the hospital for the UB-92 (medical claim form they sent the insurance company) so that I could go line-by line through the bill with the insurance company. The hospital balked and ended up calling the insurer themselves to resolve the issue. (In my case, the hospital and the insurer were part of the same company, which made them denying a pre-approved surgery even more bizarre.)

The fact of the matter is the health insurers are staffed with high school dropouts and former psychology majors making $20,000 a year. These are not people who understand medicine. They are often given simplified instructions and they often misunderstand or misinterpret them. This is why you are getting so many different stories--the barely-trained flunkies don't understand how to look at your claim file and determine what is really going on. The trick is to get your claim escalated above the flunkie gatekeepers. Ask to speak to a manager. Ask to have your claim reviewed by a nurse-reviewer. Get the claim in someone else's hands who is probably more competent. Yes, "lawyering-up" can often do that, but it can also often take the process out of your control. I'd say at six months you are quickly approaching that though.

Warren Buffett makes a fortune off of float. Many other insurance companies use interest on the float to reduce premiums--directly benefitting policyholders. This is one of the reasons (the other prime reason being that fraud tends to explode) that insurance rates often go up when the economy tanks--the stock market can't be used to subsidize the cost of insurance.

From what I've gathered, the problem doesn't seem to be that the claim is denied.

My plan is administered in Maryland, where we've got a sister company. It was cheaper for us to get coverage by joining their plan, I suppose.

Where it gets tricky is that their office (says they) cannot pay claims to out of state claimants. Instead they submit the claim to a California BC/BS office, who makes payment.

According to their records, somebody in the Maryland office did issue a check. There are notes that say the check was intercepted before it was sent out. Presumably this was because they are not supposed to issue out of state checks. Now they say that the California office says they sent a check. Nobody's received a check.

You'd think it would be a simple matter to put a stop payment on the check, wait a few days and check to confirm the check has not posted, then re-issue a new check.

But Noooooo, that's too easy. They need to open a Case File™ so that it can be investigated. There's no set time the investigation has to conclude - I suspect this is another of the "float" techniques.

Also, I cannot speak with the CA office handling the payment because they are not my provider.

So, the game seems to be point fingers back and forth claiming that they're doing their utmost to service their customer by opening a case.

It sickens me.

Are you insured thru Kaiser Permanente, by chance?

I've written to my Congressman about this. I've had good luck in the past with congressional intervention into social security problems, so figure a multi-pronged approach including this couldn't hurt.

Nope. OSF (Order of St. Francis)

I'm in a similar situation. What you say is true by what I know. However, the medical center should have a billing entity and there should be a customer service manager there. I got a hold of this person located in Orange County and she was very efficient. She in not a BC/BS employee. She works for the big company that owns many hospitals and med centers.

I didn't mention lawyers, I just said I had a complaint and wanted to make it "formal." Using the terms "formal complaint for the record" seems to be my best trump card in the last couple of years. No raised voices and no extended conversations. I tell them all the discussion should be in the complaint and I want a copy in letter form.