Today I threw a grade A hissy fit. I mean it was record worthy. It all began when I received a new EOB or Explanation of Benefits from my insurance company. EOBs are basically statements explaining what you owe to your health care provider, and what will be covered by the insurance company. For many years I was uninsured, and when I moved to Detroit, I might as well have been (my HMO was fairly terrible). I was excited when I took the job in Mississippi, because I would have an excellent benefits package (or at least a package better than what I had prior).
Yet, even with my nice new insurance, I ran into one small problem... They refused to pay any of my claims! Finally in March, I was reimbursed for half of my prior claims from November through March, and I thought all of my troubles were at least halfway over. I, however, was very very wrong.
The reason they only paid half of my claims was as follows: I had been seeing two doctors for routine visits and whatnot since October and November. They were not covering either Provider even though both Providers were in their network. Finally, they began to pay for Provider A (after much complaining on my part). They were still refusing to pay for Provider B, however, because Provider A had yet to fill out paperwork - which they claimed was vital to my services rendered by Provider B. Until Provider A faxed in the appropriate paperwork, Provider B would not be covered - even though they are two different Providers at two different practices.
They claimed Provider A had been sent paperwork twice since December, and had not received anything. My Provider claimed that she had not received anything from the insurance company relating to me. I asked my insurance company to resend the paperwork, which they did. When Provider A received it, she let me know that it had been completed, and had been returned to the insurance company. Then the insurance company claimed to never have received the paperwork.
Finally, I had had enough - I asked to speak to a supervisor. He told me to call Provider A and have her re-fax the paperwork to his line, and he would personally call me once he had received it. I did just that, but no phone call ever came - that was about a week ago.
Today, I received another EOB. I expected once again to have half of my claim denied, because I had not received a phone call, but this time the whole claim was denied. They were now denying coverage for both Providers. I thought I had had enough before, but I had not... I had barely had any compared to the enough I had when I opened my EOB.
I immediately called my insurance company, and some poor guy (I think his name was Thomas, but it could have been Dave or David) picked up the phone. I feel bad for him now; he didn't know what was coming. When he asked how I was doing, I told him I wasn't doing well and was very unhappy. I told him my claim number and asked why the company had not allowed my claim. Guess what? Paperwork. Now they were claiming that Provider A yet to fill out my initial intake paperwork, (which I know she did, because that's what they finally processed in March that allowed my benefits to finally kick in) so I lost it.
I lost it. I lost it. I lost it. I informed him that not only had she done the paperwork, but she had sent it to them months ago, and that they had already paid a substantial portion of my visits with her, and it was complete bullshit to deny my claim now. He then told me that my language was uncalled for... I lost it, again.
I told him that my language was out of frustration because they had been denying claims for months, and now they were denying ones that they were formerly paying. I was tired of being nice, and I said that I had been nice during every other phone call I made to them (which is true, FYI - I never lost my temper with anyone there until this), and I said if he didn't believe me he could check the calls himself, because after all - "aren't they monitored for quality purposes?" I told him it was extremely unfair for me to have to deal with this, and that I was sure he didn't have to worry about any of this. He could sit there and have all of his claims processed, because he worked for the insurance company, and I was going to have to call a lawyer for them actually pay my benefits. Then I asked to speak to his supervisor, and then I said "no, I want to speak to your supervisor's supervisor."
I was put on hold for 25 minutes.
I am sure they were hoping that the crazy person on line one would just hang up after a few minutes of waiting, but not this crazy person. This crazy person grabbed a chair next to the clock, counted the minutes, and reloaded.
I was ready to take aim when a man named Scott came on the line. He listened to my problem - (I explained it calmly, and without profanity). I was stern, however, and asked "why do I even pay for insurance if you guys won't pay anything?" A few minutes into my conversation it was clear that Thomas / Dave / David / what-the-Hell had sent me to the person who could actually do something about my problem. I apologized for going off, but said I didn't know what else to do, because no one seemed to be listening or doing anything about the problem on the insurance company's end. Scott then offered to take on my case personally and see to it that my claims were processed. He was going to contact the Providers directly if he could not track down the proper paperwork for me. He gave me his desk number, and told me he would be in touch, but to call him if anything else happened. I normally don't believe people when they offer things like that, but this time - I honestly believe Scott. He was the first genuine person I have spoken with at the insurance company.
I learned today that the magic word isn't please, it's lawyer. I doubt if I hadn't brought up lawyers that I would have been transferred to Scott. And, I don't blame what's-his-name for not being able to help me. He answers the phones at an insurance company. He reads off of a script, and only has access to certain information. I do feel bad for having to yell at him before I could get anything accomplished, and I hope he can let it go, because it was never my intention to hurt his feelings. The way the system is set-up, however, no one gets the help they need until they throw a hissy fit. I would never have been given assistance without raising a fuss. Like I said in a previous post: the squeaky wheel gets the grease to shut it up, and this wheel squeaks.
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