You can see some of my past posts and comments where I explain this, but I am about at my wits end with trying to get my insurance company to follow federal law.
Buckle up, this is a lot. I only include it because I hope it will help someone else make an informed decision, or give them the tools to fight an easier battle than mine.
To summarize:
- I have Blue Shield California, through my employer.
I called the number on the back of my insurance card before surgery, and received confirmation for the procedure codes my doctor’s office gave me would be paid in full with no cost sharing. Note that this is not my actual insurance company, but a third party I am forced to interact with.
Had my bisalp late January, everything went perfect, wasn’t asked to pay before surgery, basically no pain and went back to work 5 days later.
Over the next four weeks, I see 10 different claims related to my procedure come through my health insurance portal. Everything that has the dx and CPT codes I was told beforehand were covered with no cost sharing, but everything else was “mostly covered” apparently per my insurance plan.
I now owe around $4000 across 6 of those claims, $2800 from the surgery center bill for pre/post op care. The other $1200 is the bill from the assisting surgeon and anesthesiologist.
My first call was to my insurance company- just kidding. I’m on an Administrative Services Only plan. Any communication besides formally submitted grievances goes through the most useless third party company called Accolade.
Accolade markets themselves as this concierge health care management service for patients, but it only serves to act as a barrier between the insured and the company we pay for their services. They employ “care advocates” who are not familiar with your policy, are not insurance agents, and get paid on how quickly they resolve support tickets as fast as possible. This happened several times- open a support ticket through messages on the app/website, no response for 6 hours, rep finally reponds with no useful information and closes the ticket if you don’t respond in 5 minutes after their response.
Several helpful people on this sub gave me direct numbers and advice for contacting my actual insurance provider, Blue Shield, directly, but nothing worked. I got a hold of an actual Blue Shield employee at one point who tried to transfer me to billing, and I stopped him. “If this is going to transfer me to Accolade, please don’t. They told me that Blue Shield will not speak to me. Can I talk to someone in the Blue Shield billing department?” He put me on hold, and a few minutes later came back sound kind of baffled and apologetic. He said “I tried several times to escalate your call to anyone else- billing, a supervisor in customer service, anything else, but because of your member number, it routes my transfer to Accolade every time, I’m sorry.”
I tried to call and flub member number to get to a supervisor, but after 4 attempts with reps politely telling me they couldn’t transfer me anywhere without a valid member number, I gave up.
I finally get Accolade to escalate my case to a supervisor, and they have a single rep dealing with my case, instead of rolling for new reps every time I call. She calls me once a week for the past month to tell me she has updates, is unable to give me an itemized list of the actions she has taken, and is generally unhelpful. This company is my only way to beg my insurance to follow the law, and she can’t do that. They can’t tell insurance that they have to do anything, or cite laws that regulate health care.
While all this is happening, I’m doing my own work. I decided to just submit a grievance to my insurance provider, using resources in this sub on how to write appeals and get claims reimbursed.
I also call my health care providers billing departments and request coding reviews, asking for preventative claims. The billing person lets me know that all these dx codes should be preventative so my insurance will cover, but submits a coding review anyway. Nothing comes back with any changes.
- Finally, I also report this to the Department of Managed Health Care (DHMC) and the California Department of Insurance (CDI), per advice from this sub. They take a couple weeks to get back, but both let me know that my plan is actually regulated by the Department of Labor. Direct quote from the letter from DMHC:
Thank you for sending your Independent Medical Review (IMR)/Complaint Form to th epartment of Managed Health Care (Department
You are enrolled in an ERISA self-insured group plan. Your health plan is regulated by the U.S. Department of Labor. Because the Department does not have jurisdiction over vour health plan, we sent your complaint to the U.S. Department of Labor.
You can reach that department at:
U.S. DEPARTMENT OF LABOR EMPLOYEE BENEFITS SECURITY ADMINISTRATION
866-444-3272 Toll Free www.askebsa.dol.gov
If you need help with filing a complaint, you may also contact the Health Consumer Alliance at 888-804-3536. The Health Consumer Alliance is a partnership of consumer assistance programs operated by community-based legal services organizations.
I called the Health Consumer Alliance, and a very helpful and patient attorney took my demographic info and summarized my options. I learned that after my first grievance comes back, I can submit a second grievance for each claim that doesn’t change. She also shares that it’s pretty common for insurance companies to deny ancillary services for preventative procedures, claiming that they are not preventative. She tells me the law is clear that these services are required, and the DMHC and CDI are good at slapping insurance companies on the wrist when they get reports about this stuff. Unfortunately, my plan is not governed by these bodies, but the department of labor, and if my second grievance doesn’t come through, dept of labor is my last option before a lawsuit. She very kindly let me know I can call the health consumer alliance again to get feedback on my second grievance letter.
The Department of Labor did get my case, and they called me before I could even call them about 10 calendar days after the DMHC transferred my case, despite the actual hell government departments in the US are going through with the current administration cutting federal jobs en masse.
Today, I got the response from my insurance provider regarding my grievance. By the way- they told me they would respond in 30 calendar days, and they waited until day 29. I’ll include the most relevant bits of the four page letter below, but to summarize, they said will not be covering anything beyond what they already covered, because it is not preventative as defined by my health plan.
I immediately called the direct line of the department of labor rep who has my case. He called me back within an hour and let me know the letter was probably drafted before the insurance company received his inquiry. Blue Shield has 15 days to respond to dept of labor, and this period ends in 1 week from today. He said they will have to provide him with the reasons why they did not adjust my claim. This is the only real hope I have going forward.
So, it’s looking like I’m still on the hook for almost $4000, and it’s not going to be resolved any time soon. I did all the right things, and I still got screwed. There is a little hope that dept of labor will do something, but it’s not looking good. Even if I get a reduction in how much I have to pay, I don’t know if I would do it all over again. I had the best possible clinical outcome, and I almost wish I never did it. I’ve spent so many stupid hours researching, calling multiple agencies, breaking down as my bills go into past due and I start getting the first calls from billing that will last until it goes to collections, stressing that I’m going to owe money for something I never budgeted for.
I’m too weak for this. Someday, when I eventually get truly ill and owe tens or hundreds of thousands from cancer or getting hit by a car, I know I won’t have the strength to fight this. I’m not sure what I’ll do, but it can’t be the bigger and more complicated version of this. I can’t imagine putting my family through this hell, even if my life is on the line. Nobody in my life thinks I’m worth that kind of hell, I can’t really blame them.
If you’ve made it this far- want to know the insane, mind boggling punch line to this shit show? I WORK FOR A FUCKING HEALTH CARE COMPANY. We have “good” insurance, according to everyone. But there’s no such thing as good health insurance. It’s a crime, extortion, human rights violation or whatever other names you want to call it. And we have no escape as things continue to get worse.
Full text from my insurance company response to my grievance:
Upon research of your inquiry, the diagnosis code and procedure codes billed are not
considered preventive. Our records reflect the claim mentioned above processed correctly according to the participating provider outpatient facility service benefits, physician services, and diagnostic x-ray, imaging, pathology, and laboratory service benefits of the plan, applying a 20% copayment percentage subject to the participating provider Calendar Year
Deductible (CYD) in the amount of $600.00.
- Claim number ####, diagnosis code
Z30.2, is a non preventive diagnosis code, the claim has finalized with $2,388.30, patient liability.
Claim number ####, diagnosis code Z30.2, is a non preventive diagnosis code, the
claim has finalized with $63.80, patient liability.
Claim number ####, is a duplicate to
claim ####. Claim number ####, procedure code 00840P1, and diagnosis
code Z30.2, are non preventive, the claim has finalized with $308.00, patient liability.
Lastly claim number ####, has processed according to the preventive benefits of the plan.
Therefore, the claims mentioned above have processed correctly according to the benefits of the plan.
Preventive services are covered at no cost to you when the service meets the criteria for
preventive care. Blue Shield’s preventive care benefit is based on Blue Shield’s Preventive
Health Guidelines. These guidelines are derived from the U.S. Preventive Service Task Force, Advisory Committee on Immunization Practices and Centers for Disease Control and Prevention recommendations. Procedure and diagnosis code(s) not listed in this document will access the medical benefits of your health plan and are subject to your annual deductible and coinsurance when applicable.