Unhealthy Claims

Steve Abramowitz

WHEN I STARTED winding down my psychology practice two years ago, I anticipated freeing up oodles of time for reflection and for hobbies long cast aside, such as collecting oldies albums and the coveted rookie cards of sports legends. But my patient hours were merely replaced by my own spiraling doctor visits.

I was disappointed and concerned about my declining medical status. Still, I was reassured by the reputation of my health insurance company and the comprehensiveness of my policy. I soon learned I was a naïve health care consumer and easy prey for a profit-hungry insurance behemoth.

It took 26 years for the Sacramento Kings to make the NBA playoffs, and even longer for me to figure out my health insurer’s modus operandi: my health, its wealth. A self-proclaimed finance savant, I’ve been bamboozled by one of those corporate giants that periodically project smiling faces of appreciative couples onto our TV screens.

Almost 50 years ago, I smugly signed up for the premier preferred provider organization (PPO) policy offered by a large public university. I kept the policy, even after I retired from the university and signed up for Medicare, because I’ve had one cancer or another for the past 26 years and I wanted a secondary insurer that would give me maximum flexibility, plus some doctors don’t take Medicare.

Members of PPOs have the option to seek treatment by doctors outside the carrier’s network of providers. For years, I dutifully sent in our claims and blithely cashed our reimbursement checks that reflected the insurer’s contractual portion of covered costs. I didn’t check so I didn’t know that many of my claims were never processed.

Until my comeuppance, I glanced haphazardly at my claim resolution statements and routinely filed them. Then, about two years ago, I noticed that my wife Alberta’s acupuncture claims were being systematically denied. I knew the treatment was covered by our plan and thought that the information submitted qualified Alberta for partial reimbursement. Curious, I checked on her physical therapy claims. They were also rejected.

With my curiosity rapidly turning into suspicion, I pulled out the statements for my own psychotherapy visits. Again, all zeros. Aroused from my slumber and berating my irresponsibility, I called the insurer’s customer service line. That was the first of a still ongoing series of telephone calls, emails and resubmitted claims over the past two years.

My experience has been infuriating and exhausting. I have been gaslit, patronized and shuffled from one department to another. Perhaps because I had dawdled for so long, I resolved to fight unflinchingly for the reimbursements to which I knew my family was entitled. I’m both embarrassed and proud to say the problems concerning Alberta’s acupuncture treatments have been resolved and my therapy belatedly reimbursed. We are now honing in on her wrongly discarded physical therapy claims.

I’ve jotted down my insurer’s most flagrant transgressions. Be alert to them as you monitor communications from your own carrier.

  • When the insurance company decided I hadn’t provided all required information in the desired format, the claim was summarily thrown out. No record was made of the claim, so there was no way to retrieve it for correction and reconsideration. Unfathomably, I was never contacted and, since I didn’t keep a complete ledger of all our submissions, I had no way of knowing I’d been purged.
  • Telephone reps were not prepared to clarify complex and critical features of the policy. The reasons given for denial of claims changed with each customer service specialist. At one point, I was told my claim was denied because all the dates of service were not listed on the same page. After I entered one after the other, I checked back to see if all was well. I was informed the claim could not be approved because I should have done what I did in the first place. I was admonished to first send my claim to Medicare, when I was not required to do so, because certain specialties are exempt from that stipulation—information that should have been second nature to the adjuster if not the agent.
  • Medical practitioners who don’t accept Medicare patients provide us with an opt-out letter that informs the insurance company it’s now the primary insurer. I was told numerous times I had failed to send in the letter, which was not true, suggesting either incompetence or unethical practice. When I followed up with a second letter, I was told it was no longer valid because it was more than two years old. I now send a current opt-out letter with each new claim, even though the company should have one on file.
  • Certain footnotes used to explain the reasons for denial would be hilarious if not for the seriousness of the medical condition for which payment was sought. About six years ago, Alberta was diagnosed with breast cancer. She selected a highly regarded private hospital and was treated with oncoplastic surgery, a procedure that combines tumor removal and plastic surgery techniques. Claiming the process was experimental, our company refused to pay its high PPO-contracted share. The surgical team accepted a minimal payment and waived our portion of the cost.
  • Incredibly, we were chastised for not choosing in-network doctors. Are these guys kidding me? Freedom of choice is precisely why I’m willing to pay a monstrous premium for this PPO. How can a claims evaluator for one of the world’s largest health insurance corporations not know that?

Steve Abramowitz is a psychologist in Sacramento, California. Earlier in his career, Steve was a university professor, including serving as research director for the psychiatry department at the University of California, Davis. He also ran his own investment advisory firm. Check out Steve’s earlier articles.

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