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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.
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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I’m sorry about the health issues and insurance problems your family has faced. I hope better days lie ahead for you. It can be frustrating to try to get accurate answers, and as you pointed out the information from one agent seems to conflict with another. It’s worth noting that insurers provide a Certificate of Coverage that is the accurate and complete source of information related to your coverage. It’s a hefty volume, to be sure! I can access mine through my log-in portal, but it’s not easy to find, many clicks away from the glossy online brochures. I was directed on how to look for it after I exasperated my insurance company phone agent by repeatedly asking “But where can I find this information in writing?” Here’s some info that I found online which I hope is helpful to the discussion. What is a certificate of coverage (CoC)?
A certificate of coverage (CoC) is a contract that lists an individual’s health insurance coverage with their payor. The CoC details the health benefits the beneficiary and their dependents have under their plan.
Details include exclusions and conditions. Exclusions are uncovered services, and conditions are actions needed to receive benefits. Conditions may include deductibles and copays.
Individuals can usually receive a written copy of their CoC from their payor at no charge.
Why are certificates of coverage (CoCs) important to healthcare?
Certificates of coverage are important to healthcare because they provide valuable information on the terms of health insurance plans to the involved parties. Individuals can reference this information in making informed medical care decisions. CoCs also contain information that individuals can use to appeal decisions made by payors.
It’s all a scam whether you believe in Medicare Advantage or not. The only way to get critical healthcare is to have a Medigap policy and separate Rx-Part D policy to supplement Medicare payments. And, you can pick your doctor, hospital, etc. as long as they take Medicare.
Like the pundits say, you have to budget for approximately $315,000 lifetime costs for out-of-pocket, including premiums for a retired couple and it’s going up every year due to inflated medical costs, and premiums, etc.
“According to the 2022 Fidelity Retiree Health Care Cost Estimate, the average retired couple at age 65 can expect to spend around $315,000 on health care expenses in retirement.Oct 3, 2022
Steve, I read and reread your article about your very unique situation numerous times and have come to the following conclusion:
1 When I become 65, I will not obtain secondary insurance.
2 You will continue to have many of these issues as long as you have secondary insurance.
If you do not supplement Medicare you will find yourself with a 20% co-pay. Steve has a slightly unusual situation in that he appears to have an employer-sponsored retiree group plan in addition to Medicare. What most people have is either a Medigap policy or Medicare Advantage. With Medicare plus Medigap these problems disappear – I had that for several years and everything was paid with no effort on my part. Thanks to my former employer dropping the subsidy I used to buy the Medigap plan I am now, reluctantly, on a group Medicare Advantage plan. So far so good, but too soon to tell.
I highly recommend reading “Medicare for Dummies” before you have to make a decision.
mytimetotravel, hmmmmm? This article is not about Medigap or Medicare Advantage. I highly recommend re-reading the article before making a comment on my comment.
Medigap is supplemental aka secondary insurance. Medicare Advantage is alternative insurance.
Steve, thank you for your post and thank you to everyone who has commented. So much useful information.
Thanks so much. Yes, it was quite a conversation. Not everyone was in agreement, but that’s okay. It just shows how complicated it is to understand our medical choices and choose the one best for us and our families.
I don’t understand this. If you have Medicare that is your primary coverage and no insurer is going to pay as the primary carrier.
Only 1% of doctors have opted out of Medicare and disproportionally they are psychiatrists.
Having worked with many insurers over the years I think you are painting an overly negative picture. Yeah, there are screwups and many are caused by the providers office.
Are you sure you are getting the best overall value for all that you are paying versus just Medicare and Medigap?
I checked, and Medicare does not always pay first. It is, as usual in this country, complicated. See: https://www.medicare.gov/sites/default/files/2021-10/02179-Medicare-and-other-health-benefits-your-guide-to-who-pays-first.pdf
If you have employer coverage and are working, Medicare is secondary. We are talking retired people though
Yes, but. Sounds like he has Medicare A and B, plus an employer’s group plan for retirees. That’s what I had initially. Medicare would be primary for everything it covers, but the group plan may have additional coverage for which it would be primary. For instance, he mentioned acupuncture. There are strict limits on Medicare coverage for acupuncture – lower back pain only, 20 sessions/year or 12 if no improvement. If the group plan covers more, then it would become primary after 20 sessions. Easy to see how that could get complicated.
An employer plan providing supplement coverage may also cover things not eligible under Medicare. Typically there will be a spin-off directly from Medicare to the employer plan so there isn’t even claims to file.
A PPO or any plan with limited or no out of network coverage makes it more difficult. Any time manual claim filing is involved it gets complicated.
For most retirees the combination of Medicare and Medigap is the best deal with the least hassle and least oversight of healthcare.
Hi R Quinn
You make some very good and valid points. As both a patient and as a provider, I have not found the bungling and misinformation to fall disproportionately on the side of the patient.
I just don’t understand why you would choose a PPO without the intent of using network doctors. They are designed for the in network purpose.
And I don’t think “easy prey for a profit-hungry insurance behemoth.” Is a fair statement. For every claim that gets fouled up there are tens of thousands that go through without a glitch.
The profit margins for insurance companies are very similar to that of regulated utilities. Keep in mind too, that virtually all large organizations- probably your university- are self insured and thus the insurers acting as claims administrator have no financial stake in denying claims unfairly.
R Quinn
Let’s not make this a brouhaha. Some final points. At first, I thought I knew that opt-out letters would not be consequential but I was assured many times by different phone reps that their inclusion would guarantee my reimbursement. So informed and assured, I believed them. I have since had a supervisor apologize for all the misrepresentations of the reps and reimbursed me for all valid claims. We have clearly seen this issues from two sides of the playing field. You are very knowledgeable, R Quinn, but to believe that the problems of the industry are minor or not self-serving is naive.
As I posted below, Medicare plus Medigap Plan G is usually the best option for those eligible. However, it sounds like Steve would have problems with medical underwriting if he tried to switch at this point. If he has a Medicare Advantage plan I am not sure that Medicare is primary. I just acquired one and it looks like claims are going straight to the MA insurer. MA is a replacement for Medicare.
Steve, I’m so sorry you went through this. I note that Jerry has contributed his own nightmare story, and I’m sure others will as well.
I do feel the need to point out that these experiences are by no means universal. I had my own issues with various medical plans over the years, but when I incorporated to be able to buy health insurance for me and my wife, the best deal for business-based health insurance was a company I’d had miseries with in the 1990s. Anthem Blue Cross of California.
The second time around, they couldn’t have been better. During my own cancer battle (and the subsequent fallout), I got nothing but warm, fast, responsive service. When I had questions — that first $100,000 bill was a shocker — they answered them. When inevitable mistakes or oversights occurred, they dealt with them quickly and reassuringly. If my problem was over the head of the first-level person I got on the phone (which was rare), I elevated quickly and it worked out fine.
Between 2013, when the cancer arrived, and 2021, when I enrolled in the AARP Medicare Advantage plan recommended by my new cancer center at the University of Washington, I figure Anthem covered nearly $3 million worth of my bills.
No lesson here, no advice, just sharing that not all insurers are nightmares to deal with.
Steve, I hope your own cancer battle has gone well.
Hi Mike
I can only speak from my own experience.
A great reminder to all is that in the end and with due cooperation on both sides fairness will prevail.
Steve,
You’ve really been through the ringer and I sympathize. Since my wife and I have both gone on Medicare with Medicare supplement policies, I’m thankful to say that billing issues have greatly diminished.
But in our pre-Medicare days, I fought many a battle with our health insurers. I tried to always make note of the name of the rep with whom I spoke on the phone, take good notes, and when possible, get it in writing via email so as to have a paper trail.
You and Ed are right to work your way up the chain-of-command, and when you reach a person who is actually helpful, keep their name and contact information forever.
Once, long ago, I was at loggerheads with our insurance company. I read that they could be more responsive if you posted your complaint on their Facebook page. I’m not much of a FB user, but I gave it a try and lo and behold, it produced results. It’s pitiful that it took a dose of public shaming to resolve the situation.
Hi Andrew,
Thanks for the tip. Before last week’s resolution with the company, I would have tried it myself as a last resort.
Insurance companies greatest expertise is their ability to stall, dodge clear accountability and other tactics in the presumed hope the insured will give up and pay the bill themselves. I am sorry you are having so many problems.
My medicare and medigap experiences have been much more positive overall, but one stupid experience stands out. I went to my drugstore to get my first shingles shot a few years ago. I knew my medigap policy covered this but neither I nor the drugstore could get approval despite tying up the pharmacists for an hour talking to the insurance company.
I contacted the medigap administrator at my company (which provides the medigap policy) and she put me in touch with the person who manages our policy at the insurance company. He explained that I needed to submit a claim to Medicare who would deny the claim, and then I could submit a claim for reimbursement from our medigap provider. I asked why do I have to submit a Medicare claim when you know they will deny it? It quickly became obvious this was a futile argument, so I submitted the claim.
A few weeks later I called Medicare to check on the status. They soon submitted the denial and I submitted the paper work to our medigap provider for payment. Success! They reimbursed me.
A few months later I got the second shingles shot. I asked the insurer if I could bypass the Medicare claim process since it was clear Medicare would deny it. I was told no, I must submit to Medicare to start the process and I did. Again, Medicare sat on the claim until I called them checking status. After I got the Medicare denial, I sent the paperwork to the medigap provider and they paid it.
I kept a file on all the claims processing and communication. Incredibly, it was almost an inch thick with paper (no electronic option!). The total reimbursement for both shots was about $160 after my copay. Had I known how much trouble this was going to be I would gladly have paid everything out of pocket.
I have a happy if frustrating ending. The executive I had contact with on Friday (see below. response to Time To Travel) just contacted me. It’s done. Glad you also had a Hollywood ending.
I’m sorry this happened to you .Medigap doesn’t cover shingles shots. It’s covered by the Part D prescription plan or Medicare Advantage. This must be something specific to your policy because I and other family members have received the shingles vaccine – not subject to a either a deductible or a copay. I have never needed to submit a claim to Medicare for a vaccine or any service .
You are very fortunate indeed. My insurance as the second party does not cover any claim but health insurance and a few other incidentals without first sending it to Medicare.
We got our shingles (Shingrix) shots in 2022 and I guess our Part D plan wasn’t as comprehensive as we had substantial out-of-pocket costs. I wish we’d waited till 2023 since they would now be without cost: Medicare and Medicaid to Fully Cover Preventive Vaccines in 2023 (ncoa.org)
Welcome to the realization that your interests, and those of the medical insurance industry, are diametrically opposed. This is yet one more example of why we need single payer healthcare. I’m sorry this happened to you, and even more sorry that it happens to many people in the US, all the time. (You can meet some people dealing with similar situations here: https://armandalegshow.com/ )
If you are Medicare eligible you should look into a Medigap plan. I believe that the best coverage available in the US is Medicare plus Medigap Plan G plus a cheap Part D plan. That is what I had until this year, but unfortunately my former employer has replaced the flat subsidy it was paying with a group Medicare Advantage plan. It is a PPO, and I pay no premium and have an out of pocket max of $750, but I am uncomfortably aware that if it is reduced in the future I would be unable to return to Medigap coverage without medical underwriting.
I am puzzled that you didn’t realize the situation earlier – weren’t your providers billing you?
Hi Travel
Yes, they were billing me. The problem was “misinformation” (their word) I had received about the opt-out letters. I was told multiple times I needed Medicare opt-out letters with all the claims. I thought I had the problem solved when I was told the opt-out letter had to be sent in with each claim. I had my providers go to the trouble of furnishing me with a letter for each service. Still no action and no rational explanation. Friday, when I spoke to the executive, I was informed the opt-out letter was only valid for behavioral health claims. In all other cases, it had no relevance. I had spent a good part of a year becoming expert about something that was part of the “misinformation” I had received. Only after I threatened to go to the university, did she agree to pay all claims. But, like I said, she has not (yet?) gotten back to me. Apparently, my education in health insurance finesse is not over.
“This is yet one more example of why we need single payer healthcare.” We are, or will be, patients one day—even the people who run these insurance companies. Why on earth is it not evident by now that other countries have figured out better healthcare at less cost? We are used to voting against our own interests.
Steve, I’m sorry this happened to you. Consumer ignorance of medical billing practices is both costly and heartbreaking. My wife is diligent with our own and extended family, and has saved us thousands of dollars. But the cost in telephone time is burdensome and maddening.
Hi Ed
Heartbreaking is the word. If with all my so-called higher education I’m having these problems, what chance does the average Joe have? Although I don’t believe the company has an ulterior motive here, I think the all the obfuscation has the unfortunate effect of putting a roadblock in front of claims-filers, who then just give up.
Bureaucracy, private bureaucracy. And, yes, they do have an ulterior motive: profit at all costs.
When my wife was recovering from an illness that hospitalized her in 2021, I took over the duty of dealing with the billing. With both the medical provider, who was my employer, and the insurance company, I patiently and politely, yet persistently, worked my way up the chain of command or laterally to a different department. I spent as little time as possible with a person who didn’t have an answer I wanted or couldn’t make a decision. We eventually worked it down to figure we were responsible for paying.
Hi again Ed
I hope many people read your post because it is a pearl of experienced wisdom. I think the strategy of moving up the ladder can be very effective. It is hard to keep from blaming the first-line representatives, who are asked to be fluent in so many complex provisions of the policies. I finally got high enough in the bureaucracy to hook up with a company executive who was both knowledgeable and personable. We agreed that I would fax her the claims and she would “take care of it.” She also agreed to confirm receipt of the claims package. That was Friday. Ed, can you believe she never got back to me? Fortunately, I took down her phone number and plan on calling her today.I have never complained formally about any service or product in my life, but in the interest of the many employees who aren’t aware of what may be happening with their claims, I am strongly considering informing the university.
Wow, Steve. Reading your story made me more and more upset as I went. I’m so sorry to hear about your struggles to get rightfully reimbursed.
My wife and I have had some issues with medical bills in the past as well, but it was from out of network doctor practices operating in our in-network hospital that we had no way of knowing about until after the fact. (Presumably this practice is outlawed now due to the “No Surprises Act”, but I have seen stories that it still goes on.)
The medical system we have in the US is certainly a convoluted, confusing, frustrating mess for the patients and it really doesn’t need to be.
Ugh. This reminds me of a couple years ago in our previous medical group when they recommended a “diagnostic” mammogram because of my “dense breast tissue.” I’ve never had any suspicious mammograms or otherwise and no family history. But I did what they said. Little did I know until I got the bill that they used an out-of-network doctor to read the mammogram and I had to pay that out of pocket, even though mammograms are supposedly covered by my PPO. No surprises, indeed.
AUUUGGGHHHHHH!
Hi Nate
Thank you for telling everyone about the “no sunrises act.” I plan on consulting it so that next time I face similar roadblocks I will have a legal weapon to brandish.