God grant you the light in Christmas, which is faith;
the warmth of Christmas, which is love;
the radiance of Christmas, which is purity;
the righteousness of Christmas, which is justice;
the belief in Christmas, which is truth;
& all of Christmas, which is Christ.
--Wilda English

Tuesday, July 24, 2012

God, Give Me Patience!

When I was but a youngster receiving my education at the local catholic school, one of the nuns (can't remember which one) had a way of responding when one or more of us kids exasperated her.  She would stop whatever she was doing, close her eyes, & mutter "God, give me patience!"  After dealing with my insurance companies, particularly during the last 2 years, I feel that sister's pain to the nth degree.

I just want to share with you my struggles with one of my insurance companies in particular.  Yes, I have more than one.  I have three.  The third is a government entity. You would think that explanation is all you need to know ... that you totally understand what I've been dealing with ... but believe me, you have NO idea.

The way this government connected insurance company is supposed to work is this.  I submit a claim to my primary insurance company for money I've paid to a doctor or pharmacy out of pocket.  They either reimburse me a portion of that claim or they deny it.  My next step is to submit the claim to my secondary insurance company.  They likewise either reimburse me a portion of the claim or they deny it.  The final step is to submit the claim to my third insurance company.  I was informed by them that if a claim is not reimbursed in full or is denied by the first two insurance companies, they will reimburse me whatever remains be it a partial or total amount.

Things were going along smoothly with this government entity until about a year ago. Suddenly claims were taking longer to process, & then when I would finally receive a response from them they would oftentimes deny the claims for reasons such as these:

1.  The claim is missing necessary information. It is here that I wonder what they're referring to because the information they are saying is missing is right there, clear as day, on the paperwork.

2.  The codes are incorrect.  Upon checking with the doctor's office or the pharmacy, I am assured the codes are correct.

3.  I should have submitted the claim to my primary & secondary insurance companies first.  The Explanation of Benefits from both the primary & secondary insurance companies showing what they paid or did not pay are always included in the paperwork & are noted as attachments in my cover letter.

They come up with other reasons as well but I think these three probably give you an idea of what I've been up against.  However, even I was surprised by what happened in May.

Prior to January of this year I had been getting reimbursed in full for a very expensive medication I literally need in order to have any quality of life whatsoever. Insurance company #1 does not handle this particular type of claim.  Insurance company #2 does but they say the medication is not necessary even though the doctor & the hospital tests say it is.  I therefore have to pay for it out of pocket & then submit it for reimbursement to the government entity, insurance company #3. However, only 50% of my January claim was paid to me with the explanation that insurance company #2 paid the other half. They of course did not.  I called & spoke with a representative who agreed that a mistake had been made & he would reprocess the claim.  I would receive the remaining 50% owed to me in 4 weeks.  That amount of time passed & I had not received anything so I called again.  This second representative indicated there was nothing in the computer to indicate I had ever called before.  He agreed that a mistake had been made ... I should have received 100% reimbursement ... & he would reprocess the claim.  He said I would receive something in 4 weeks.  Once again that amount of time passed & I had not received anything so I decided this time to explain the problem in a certified letter.

On April 4 I received a response from Theresa L. telling me she reviewed my file & my request for reprocessing the claim in order to reimburse me the remaining 50% was denied because I did not secure preauthorization from insurance company #2.  (I did so secure that.  I submitted it with my claims each & every time I sent one in.) Theresa L. then went on to say that it looked to her like I probably shouldn't have been paid the first 50% either.  I then chose to file a formal Notice of Disagreement & did so on April 17.

On May 22 I received a letter from Tim B. This letter sadly showed the type of people ... government employees ... who process claims. I will share with you below the body of this letter.  If you have any pride in the written language you may want to take a Xanax or two before you read it.  I definitely had to take one after I received it.  I have placed explanations in brackets where I do not want to include personal information or where I need to explain something further. The spelling & sentence structure of this paragraph is exactly as it appears in the letter.

_____________________
Dear [my full name here],

In regards to your request.  Your claim 1/4/12.  After review of this issue [company name misspelled] paid the claim in error. This is why; you have to follow the rules & policies of your primary Ins.  In the letter from [primary insurance company] date 4/22/10 it is showing that the prior authorization request for the coverage of [name of medication] was denied due to the results of the [name of hospital test] did not match the policies.  There for we should have not paid the first claim.  There is an avenue that can be taken, need to call your other Ins & ask for an appeal for this claim if & when they do so return the claim with the approval & we will reprocess the claim.
_____________________
NOTE:  I had tried to obtain preauthorization from insurance company #2 two years ago but it was denied.  As stated above, insurance company #2 determined that I don't need this medication even though my doctor & the hospital tests prove otherwise.

Two weeks after receiving the May 22nd letter I received a Notice of Indebtedness informing me I owed the previously paid 50% of the claim I had been reimbursed in January due to lack of obtaining preauthorization from insurance company #2.  

ANOTHER NOTE:  Since the hellishness of this January claim I have been receiving 100% reimbursement for all other claims for this medication, no questions asked.  

Does this make sense to anyone?  

Yesterday I received two more responses regarding separate claims submitted to this insurance company for reimbursement.  One reimbursement is for two medications although the claim was for six.  What is happening with the other four?  This was a resubmission because all six claims were initially denied due to missing codes.  The codes were clearly there.  Upon resubmission I highlighted them & sent a cover letter pointing them out ... but guess what.  The codes they listed for the two reimbursements they paid are generic codes. ?????  The other response I received is denying me payment for something I didn't even submit to them! 

Perhaps it would be a good idea for the government to issue t-shirts to their insurance entity employees to wear while at work with the following words emblazoned on the fronts.
   

19 comments:

marly said...

Good Lord Shirlee. I'm not surprised at all. When my husband graduated college and was looking for work, two of the government job openings were given to relatives of current employees who didn't even take the required civil service exam. One is now in charge of the entire branch, taking his boss's (father-in-law's) position. Paperwork is manipulated for many of these positions and there should be a policy against relatives, who are hired as favors and not qualified. I would pay the amount and let it go before they look further and say you owe them for the other reimbursements! You can't fix stupid.

Девушка с пяльцами said...

Here in Russia there is the same policy! Shirlee, I wish you great patience!

Nancy said...

Shirlee, I am going to give you a very big stick to use with these insurance companies. With this issue getting larger and larger, send a letter to all of the companies and tell them that they better look very closely at everything involved in your case and straighten it out. IF NOT, you are going to contact The Insurance Commission and have them look into it for them. Insurance companies cringe in major fear when the Insurance Commission is mentioned as they can be fined big time if they are found to be at fault and most times they are. They feel that they can do what they wish as most people will just let it go. Believe me, Shirlee, I used to work for an insurance company and have on a personal basis had to use this threat and it worked perfectly! They had the problem fixed within a week and I had no problem with them afterward. Any time I would call about a problem or mailed something in, it was taken care of promptly.

butterfly said...

What a nightmare Shirlee . Hope you get it sorted soon.

Vickie said...

ooOoo! I love Nancy's idea! Do it! Do it Shirlee!! I am going to remember that too. You are not the only one dealing with insurance idiots.;)

cucki said...

ohhhhhh nooo
i hope you get it sorted this all sooon.
take care xx

Lei said...

What a mess. I hate that you are having to go through all that but unfortunately that seems to be the way of the world these days. Hang in there. It will works itself out before long.

Pam in IL said...

I'm so sorry you are going through such a difficult time with your insurance company.

Every single claim we submit goes through this same denial process. I spend way too many hours trying to get it straightened out. I personally believe the insurance companies do this in an effort to get out of paying a claim. I think alot of people get so fed up with the insurance company and all the red tape that they just pay it to avoid being turned over to collections.

Hang in there and know that you're not the only one going through these type of insurance nightmares.

Chris McGuire said...

Wow. Talk about frustrating. My heart goes out to you.

On the issue of patience, I always say that we need to be careful asking God for patience... He has a tendency to TEACH us patience through trials rather than grant us patience :-)

Chris

Dawn said...

OH Shirlee, bless your heart for your patience! I deal with a primary and secondary and go back and forth and sometimes I give up because they get me confused in the end and the doctors offices are rude when you mention incorrect billing codes! ughh, I feel your pain, I do miss our free military benefits, go to the doctor and no bill, gets meds, no bill, I think I'll send my hubby back to the recruiters, lol. I'm having a hard time adjusting to civilian life and methods.
I love Nancy's idea, I think i need to look back into this myself.

stay strong dear friend

TheCrankyCrow said...

Ohhhh....ouch....that made my head spin in circles (and that was just the grammar and structure of Tim B. Idiot's letter). Unfortunately, I've had similar situations (although, thankfully, not with 3 different insurers being involved.) Even having a law degree doesn't prepare you for that kind of stupidity. In fact, in my last go-around, I did play the attorney card, and the gal I was speaking to laughed and said "yeah, if you're a lawyer, I'm Marilyn Monroe." Hello??? I gave her my state bar id and asked for her autograph.... Wishing you the very best of luck....and patience. (I hope those are some damn good drugs you're getting....) Smiles & Hugs ~ Robin

Maggee said...

It is a SHAME that we have to constantly go back and CORRECT stuff that others have done in our lives, records, claims, well--EVERYthing! It IS the way of the world, and I sure don't like it! I saw the change coming when my kids were in school, and they brought home papers with OBVIOUS spelling errors on them (which really IRKS me!!)and perfect grades! Hello??!! When I asked about it, I was told they don't want to hurt their feelings... That was 20 years ago, and it has only gone downhill since! I have taken so much personal time and devoted it to following up on matters that should not be mine!! Go to the next level--the Insurance Commission. See if that works, and we WANT to know! Rant over...Hugs!

Judy said...

Oh the pathetic Insurance companies! They run our life--no matter what the doctor says! I work in healthcare and deal with codes for tests everyday. Whoever wrote these codes, had no idea what is actually involved with what the code is for! It is ridiculous. The claim people have no idea either! It gets worse everyday too. Most companies are exactly like this. I am sure they spend more time trying to get out of paying benifits...while we pay high premiums for the coverage. I wish you luck.
Judy heartland stitcher

Chris said...

Wow. What a racket. I am so sorry that you have to go through this. It shows you what is broken with our system. I work at a pharmacy and it is amazing what insurance companies do, add deductibles, increase co-pays, make drugs prior auth, etc. All so that they can keep increasing their profits.
I am disgusted.

Sally said...

Hello

I'm a new follower of your blog.
What a nightmare for you.
I hope you can get this sorted soon.

Michelle said...

Oh Shirlee hope all this gets sorted for you soon - sending you a hug xx

Janet P said...

What a complicated way of doing things, thank goodness we don't have this in the UK. Money is taken out of our wages each month what they call national insurance this pays for whatever medical treatment is needed. We have to pay a set fee for prescription drugs unless you are a pensioner and then it's free. There are other benefits also. It's not always a perfect system, but we are very proud of our National Health Service here in the UK. Good luck in your hunt for justice. x

Anne said...

Oh my Shirlee. I'm flummoxed at the US's insurance companies and how they are run...by idiots and swindlers!! You have 3 insurance companies and not one can reimburse your meds without drama?!?!? Oh boy. So sorry to hear about this massive problem you are dealing with. Hugs to you!

Suzanne said...

I am so sorry to hear of about the nightmare you are having with your insurance company. I always complain about what our insurance company covers here in Australia, but at least the percentage that is covered or the dollar amount that is covered it set and usually stays that way for a year or so.

I hope that you are able to resolve this problem.