Ep 13 Claim Craziness Pt 1

This is Dr. Patient, a podcast that examines all the aspects of the patient provider relationship. I'm your host, Heather Johnston, MD, a real life doctor and patient. Hi, everybody. Today, I'm gonna let you in on a mini saga I've been going through for a few months with my health insurance company United Healthcare. I'm talking openly about this because I think that most of you listening will be able to relate on some level. And, we can probably all agree that there's nothing too much worse than trying to communicate with a health insurance company. Before we start, just a note about the different players in the world of employer based health insurance. That's the kind where you get insurance through your work. This might seem obvious, but trust me, it gets confusing. Let's start with the employer. The employer contracts with a certain health insurance company and arranges for your health plans that you, as the employee, choose from. You, the person who gets the health insurance for yourself and maybe for your family are called a member. Employer and member. Last thing to give you a heads up on, is it this is a part one of a two part story. Think cliffhanger. Okay, here we go. My family decided to stay with the same health insurance company that we had last year. It just happens that my husband owns the small family run business where we get our health insurance from. So he's in an odd position of being both a member and the employer - this will be relevant to the story. As the employer, each December you have to fill out renewal forms with the health insurance company if you're sticking with them, basically letting them know that your employees intend to continue with them. It just so happens that as a doctor in the family, this task falls to me, which is hilarious because a lot of people seem to think that doctors actually understand their own health insurance better than you do. Quick Revelation we don't. About two weeks into January of this year, I go to Walgreens to fill a prescription for my son for medication that he needs to take every day. And I'm told by the Walgreens pharmacist that they're getting an error message when they run our health insurance card that says that my child's gender is wrong. I asked them to rerun it, I swear he is a boy. And they say there's nothing we can really do. I have to work it out with the health insurance company. The next day, I call the United Health Care member service line, the line that you call if you're the person receiving the health insurance. At first they said we don't see anything wrong on our end, and everything seems fine. I push back more and ask them to dig deeper. So they put me on hold for about 10 minutes. And they come back and say wait, it looks like you guys didn't renew your health insurance. So currently, you do not have health insurance. Okay. Remember, I mentioned earlier that I just so happened to be the person who fills out the forms for the company. So I know that it was renewed because I am literally the person who did the paperwork and submitted it for the company, and I did that all on time in December. The Member Services person is saying that I did not. So I spend the next few days on the phone going between the member services representative and the employer services representative who assures me that she in fact did receive all of the forms on time and that they were filed successfully. And all done quite beautifully. I go back to Walgreens a few days later and say hey, can you run the health insurance card again? And this time, the error message is that my child's birth date is wrong, which we now know is a crock of you know what, and it is United Healthcare as a way of saying that things are not yet fixed. But now we're starting to get to the point where my kids about to run out of medication. So I go back to Walgreens and I say look, my kids almost on a meds and I have to get this resolved. She runs the card again, it's not working. Today's error message, by way of Russian Roulette, is that it is an invalid group number. So I say to the pharmacist, well, I need the medication, what are my options? She says the only option is for you to pay out of pocket and then get refunded for it later when this all works out. And I said well, will I get refunded through you like Walgreens or through United Healthcare/ She says United Healthcare. This all makes sense to me. So I step out of line just to be sure and I call again, the United Healthcare Member Services line. I say hey, this is what the pharmacist is telling me is this accurate about getting refunded? And they say yes, since we still haven't fixed the problem, you'll get refunded for that when it's all worked out. So I go back to the pharmacy, I say great. I will take a one week supply please. Which at two pills a day is 14 days. The total is $108 plus change, which is a lot but I go ahead and I pay the $108 for 14 pills and yes, there will be a future episode on drug costs. I take the medicine home and great, my kids happy, it's all good. I will not go in to the three more phone calls I made to the United Healthcare Member Services representatives to ask if things had been resolved and was told that they were not. But about three weeks later, it somehow gets worked out. No one calls or emails me about it or anything. I just happened to be in Walgreens for something else. I check in with the pharmacist, who's pretty much becoming a close friend at this point, and I say please, can you run it again? And yes, it goes through. So I say to the pharmacist, okay, well, now I guess I just need the rest of the prescription. At two pills a day for a 30 days supply, that's 60 pills minus the 14 I've already paid for. She says got it. Pick it up the next day. And after I'm already home and I open the bottle, I see that there's actually 60 pills in the bottle, not 60 minus 14. And I think well, at this point, I'm just going to leave it because my blood pressure honestly can't take too much more back and forth about it. So now insurance is showing is valid, check. Got all the meds, check. Now it is time to file for the refund. I go online to my uhc.com. That's for my United Healthcare.com. I go to the claims tab, find the correct form for reimbursement. I download the form, print it, fill it out and then scan it. And I scan the Walgreens receipt showing that I paid $108 I even scan the screenshot that the pharmacist had taken on the day I paid, proving that they could not run the insurance that day. And I submit all that I go off, live my happy life. And three weeks later, I get a letter from Optum, which is United Healthcare's partner company that handles, among other things, their drug program. And the letter says the claim has been denied. And the reason given is, "prescription filled too soon for payable benefit". This is what they say when you fill a prescription and then you go back to soon to get the next refill. Like if I go every single month to get a prescription but one time I go 15 days early, they'll say well, probably, "prescription is filled too soon for payable benefit", and they won't cover it. But remember, this claim is for medication that I bought out of pocket before I was even able to fill a prescription. So the given reason for denying the claim, that I went too soon, is obviously BS. And I'm shocked at this. I can't understand it. This is not how it was supposed to go. But then again, I think at this point, am I really surprised? And yes, the answer is yes, I am still surprised that the incompetence can just keep coming like waves. So guess who I call next? You got it. I call Member Services again for United Healthcare. Since by the way, there is no direct number for their partner company who denied the claim Optum. And I say I don't understand this, I need some help. Of course, each time I call by the way, I have to start the whole story from step one. And as you can tell, since I've already been talking to you for like 10 minutes, every phone call takes a while. So this time, after I've explained it all yet again, the person on the phone says my only option is to file an appeal with Optum. At this point, I'm pretty fuming, especially because Optum seems very hard to get ahold of directly. So I asked this person to transfer me to a supervisor. This is just a weird case, I say. It's nothing personal, but I'd like to talk to somebody with more experience. Pro tip there. So United Healthcare Supervisor, L I will call her, comes on. She's really nice. I explained the whole thing again from the start. She says yes, it sounds like you absolutely should be refunded for this. It seems ridiculous. Let me get on it and investigate this for you stay on the line for a bit. She comes back about seven minutes later and says okay, I think I see what some of the problems are. It might be related to the fact that when you eventually went to get the rest of the prescription filled, Walgreens gave you the whole 60 pill/30 day long prescription. And this makes it seem like you got too many pills over the prescribing time, but that's not your fault. So she says what I'd like you to do is send me an email with all the pertinent information, all the scans, all the receipts, and I'll work on this for you. So nice, right? Oh my gosh, I'm thinking this is great. Yay, supervisor L, she is on it. A few weeks go by and I haven't heard anything. So I email L. Hey, I haven't heard. I'm just checking in you know, how's this going? I don't get an email back. And another week passes by. And then I get a random phone call from someone with a different name saying hi, I'm calling from United Healthcare. My name is D. And I'm calling just to let you know that your claim has been denied. And I say, I don't understand, for what reason? And she says, Oh, I don't know. I've just been asked to call and tell you, you know that it's been denied. And I said, Well asked by whom? And she says, well by the department, you know, the claim department. I'm thinking, Okay, you called to tell me you won't pay me back. But you will not tell me why. Like, it's a secret. Now. What is going on here? So I'm trying to be nice, because I know that this is not this lady's fault, right. So I say, okay, look, this is just getting insane. I talked to supervisor L recently. Can you get me to her? No, I don't know who that is, she says, and you'll have to just wait for the letter that we'll send that will give you an explanation of why the claim was denied again. So I get on the computer, I email back my previously friendly supervisor L. Hey, I just got this call from some other random person. She can't explain why this is happening. I thought you and I both agreed that this charge was very obviously, you know, obviously should be refunded. Can you tell me what's going on? Is there anything else you can do to help me? Here friends, sadly, is the cliffhanger. Because contacting formerly friendly supervisor l was the last thing that I did. And that was just a week ago. And I'm still waiting to hear back from her or anyone else. There are still more steps I can take if I get another denial, including appeal after appeal to increasingly higher up people in departments. If none of that works, I will end up probably having to go through the health care section of the Illinois Attorney General. And that'll be in the next episode. I figure I've spent enough time on this so far that if I was getting paid to do it, I'm probably making about $4 an hour for my time. And I wonder if this is part of the ugly underbelly of the insurance claim system, that they just wear you down until you give up so that they can avoid having to pay out for claims. But I will not relent, for my sake. And for yours. I will not give up until there's nothing left to do, at which point I will probably make a part three to this story that will contain a lot of expletives. So, I'm going to ask you for now, stay tuned for part two, which will hopefully include a resolution of some type. And I'm as curious as you are to hear how this is actually going to work out. As always, thanks for listening. Thanks for listening today. To catch up on more episodes and to get new ones delivered directly to you. Subscribe wherever you find your podcasts, Apple, Google, Spotify, iHeartRadio and more. If you'd like to be a guest or have an idea for an episode, let me know at wwwdrpatientpodcast.com. That's doctor patient podcast.com. Here's the disclaimer. Even though I am a doctor, I'm not your doctor. These stories, my comments and all discussion is purely reflection about what's working in the healthcare system and what isn't. Don't use any medical information that you hear in these episodes to diagnose or treat yourself. If you have a question about your health, get in touch with your doctor or local health clinic