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.