A note from myself before I begin:
I have been waiting a long time to write this entry. This is the entry of my meeting with one of their vice presidents. In this scenario there was no blow up like there was over the phone. There was nothing said that was derogatory. However, if you pay attention to the details and the subtle answers, you will realize why I was shaking with fear, anger, and worry for other customers of this insurance company who either did not know better, or did not have time. I appreciate all my readers, but I ask, please share this entry. Of any of them this is the one to share, not the most shocking and mind-blowing, but the most important to gain insight into the thinking of the head office of insurance companies.
You read it correctly in the last entry, I was denied my back shots, because I needed physical therapy according to their medical managers. After they learned by reviewing documents from my physical therapy facility that I had 8 years of therapy, only then did they agree with the shots. If I had not appealed and fought again, I would not have been granted the medical treatment I needed. After it was approved, getting the back shots took two more weeks, because I had to reschedule due to the medical manager being the same person on duty when my appeals manager said they had enough information to overturn the denial. It is policy I was told that medical managers could not correct their own mistakes. Someone else had to approve the changes, and there was no one else working to approve, this insurance company was okay with leaving me on the floor writhing in pain. So much so, my pain manager had to double my opioids to help me sleep and relieve the pain for that duration. It seemed that the insurance company did not think about the opioid epidemic or addiction. Keep in mind their excuse was they wanted to make sure I was getting the right procedures that I needed, not to save money. So, I lay on the floor those two weeks as stated, begging for relief. Not even my tens unit helped (a device that sends electric currents through you to help relieve the pain.) Please keep all this in mind when I discuss the meeting.
Frustrated, I lay on the floor after talking with my appeals coordinator, learning that I could not receive my back shots for another two weeks because the high and mighty medical manager could not correct himself with the new information that my coordinator received. Not only did she have my word and claims, she had the physical therapy institution send her all of my medical history. She had all the information right in her hands. My approval for relief was within her hands. However, the insurance company policy stated, she told me, that a medical manager who denies a claim cannot approve it, even with the information needed.
I was appalled. In my line of work if I made a mistake, we were encouraged to fix it on our own, not have someone else do it. I told her that I will have to be on the floor two more weeks and all she offered was an apology and wished me well. To me it sounded like, “Due to our red tape and policies, you are screwed. Thank you and there is nothing you can do, have a painful day.”
It was this call that broke the camel’s back. I scoured the Internet looking for the CEO’s email address. I could not find it. It was not posted anywhere and I consider myself a pro when it comes to looking for information. My old CEO’s email address was on their website and you could go visit him at his office anytime you wanted. So, I ended up sending an email on their website on the “Contact Us” page.
Within a two days, I received a phone call from them. It was the CEO’s administrator. I voiced my concerns over the phone and she stopped me in mid-sentence. She stated that they are another part of the company that concerns themselves with the doctors and patient procedures, my issues and concerns were with their second part of their company that handles customer approvals and claims. I said, “Wow!, I do not think anyone knows that nor did anything state that on my search on the Internet”. She said not to worry she will send them an email of our conversation and that someone from that part of the company will get back to me in a few days.
I found this to be suitable and ended the call with her, thanking her for her time. A week passed and I received nothing. Not an email, a phone call, a letter, nothing. I was not shocked. I called the CEO’s administrator and told her they may work together, but they do not pay attention to her because I received nothing from the other company, even though both companies were under same corporate umbrella. She was not happy and told me that she guaranteed I will hear something soon as she was going to call them.
The next day to my surprise, I received an email from the lady who reprocessed my 2015 claims, and found that I needed to be refunded $785. (This was covered in The Story Part 1). She stated she was aware I sent the email and that she will handle it. I thought she must be the only one that handles the “shit” that comes through their system.
It took a few emails and about three weeks to nail down a date, but they offered to meet me at the same hospital my wife was working at the time. This facility was only 30 minutes away, whereas their home office was over 2 hours away.
I thought this was very kind, and told them I will meet them there in three weeks.
During the waiting period, I was finally able to obtain my back pain shots, (I will discuss this procedure in the next entry). They seemed to relieve some of the pain. When I woke up the day of the meeting, I was very sore in my back at the injection site and told my dad I will need my scooter to go through the hospital to get to the conference room that was reserved for the meeting.
Dad picked me up, transferred my scooter from my car to his and proceeded to the assigned hospital. We discussed what we wanted to say and what points we wanted to make clear at this meeting during our thirty-minute trip. By the time we were satisfied, we arrived in the hospital’s parking lot ready to go in.
Trailing behind my dad in my scooter, we entered the hospital at the main entrance and made a left turn towards the elevator to the second floor. As we exited the elevator, we were greeted by the lady that helped me with my prior claims. She knew who we were based on my scooter and the details I gave her about it. I told her in advance it would be very easy to spot us.
She led the way to the conference room and told us the vice president would be with us in a few minutes. As we waited we greeted each other and thanked her for helping with my prior claims. Afterward, it did not take long for the conference room’s door to open, and the gentleman I had been waiting to meet for a long time entered with his planner in hand.
He also was very nice and greeted us and shared a few pleasantries before we turned to the real reason we were there. The meeting lasted over two hours, I will summarize the important parts of the conversation:
I did almost all of the talking for the two hours we were there. I told him how his assistant helped me reprocess all of the claims in 2015 after I found 7 big errors, and that her staff found 5 more, for a total of 12 errors. Most of the errors were processing the claim at a tier 2 level instead of a tier 1. A tier 2 level would put more financial responsibility on the patient due to the doctor or facility not being a priority participating provider. I also shared with him that a person on their customer help line admitted that their tier levels were very confusing. I then told him that I responded back that if I knew the difference, the people getting paid by the company should know the difference. I should not have to waste my time auditing their work for free.
I then looked him in the eye and asked him, “What if I was disabled to the point I couldn’t understand your Explanation of Benefits or processing? What if I was too old to comprehend what was done? If I got paid back $700 plus dollars, how many members deserved to be paid back? Even your own employees are admitting to the members that their benefit system is confusing. Is that what you are going for? I never had this issue with Highmark. It was either approved or not approved. Also, at least in my experience it was 100% approved without a phone call.
After I paused, he looked down, writing a summary of what I was saying and without looking back up to me he stated that he knew that was an issue. “HE KNEW!” I raged in my mind. Did he just admit that they knowingly were ripping off their members, if the members did not understand the claim process and fight like I did? In my opinion, this is exactly what he just said! I paused before I continued on.
Second, the insurance company has to work on their image. When I had told my doctors my insurance was changing to this company, all of the physicians, said, “Good luck getting your procedures approved”. In one instance I had a doctor order everything he could when I still had Highmark just to make sure it was approved. I asked the vice president, “How do you think I felt knowing that it seems that my doctors are telling me that his company cares more about themselves than they do about patient care?” Once again looking into his eyes I waited for a response.
He stated, “I know and we are working with them on that. These are things that we have been hearing about for awhile.”
“HE KNEW!” I screamed the words in my head, wondering why I was wasting my time and putting myself through this, sitting here in pain. He knows the issues his company is facing. I decided to move on to my next point.
Third, I thought the doctors were thoroughly mistaken when they anticipated there would be difficulty getting a second brain MRI approved. After all, my first brain MRI went through with no issues. I even told my doctors they were wrong for doubting the approval process. My new insurance company did not have a problem approving tests for their patients. They only had an issue paying for them correctly. That was until my second Brain MRI was requested by the same doctor stating it was a follow-up after an abnormal one. I told him I received a denial letter and appealed it right away. When I talked to the appeal coordinator she stated, that they do not look at prior medical records for the first approval, they look at the documents that doctor sent with the request. She stated for MRI’s they even have a third party company help them make decisions and they do not have access to patient history. I then asked her how can they know what is best for me if they are denying claims for tests that doctors who do know me better think are necessary? She had no answer, but had stated they wanted to make sure I was getting the right care I needed. After hanging up, she called me the same or next day and stated she received the approval. She added that the medical manager looked at it and agreed it was a follow-up and he had no idea why it was denied. “That’s just great”, I thought. I told him after the second brain MRI was done they saw my tumor had grown double in size and now there was a second tumor. What if I hadn’t fought it? What if I hadn’t followed up? What if I had accepted the claim denial, had never gotten the test done, and the tumor had grown over 10 mm and I had started to lose my sight? I asked, “Do you know how many senior citizens take your first denial and then never get the test done?” I paused again waiting for an answer.
Once again, I had the same response. “I know, and I am sorry.”
At this point my voice was getting hoarse. My dad had sat in his chair for over an hour, quiet, but he knew and could tell the pain was getting to me and that I was beginning to lose my voice. He looked at the VP and stated, “My son knows your company inside and out. However, other people do not. He had to make plenty of phone calls to know how everything worked, he had to go through hell with his pain, but he learned. We know that your company might be taking advantage of sick individuals that cannot review their claims, seniors that might not understand, or people who just do not know. You might be able to get away with it 99% of the time, but you’re not going to get away with it with us.”
I thanked my dad for the break. I said fourth, your company denied my back shots after it was suggested by an ER doctor and a spine specialist. Before I was able to see that spine specialist I first went to the ER. I was in so much pain I had no choice and could not wait for the appointment to see the specialist. My dad took me to your insurance company’s emergency room. In about an hour a doctor came into the room and seemed to stall at ordering an MRI. He stalled until I threw on the hospital bed 120 plus oxycodones in a bottle and told him I do not need your pain meds, I need your MRI. Four hours later, I finally had one done. It showed I have bulging disks, a not moderate, but severe arthritis on my L4 and L5 vertebrae with minor arthritis going through the rest. The ER doctor stated I needed back shots, the specialist I finally saw agreed that I need back shots. However, your miracle medical managers stated I did not. The same medical managers who did not know me or understand the situation I was in. They wanted me to go to physical therapy first. Well, after some very angry phone calls to my appeal manager, it was approved, and she told how it couldn’t be approved until another medical manager was there because the one who denied it was the only one on duty. I stated, “How, dumb is that? A medical manager cannot approve his own mistake. In my job we fix our own mistakes. I mean you have to be the dumbest company in the world to have a policy like that!” I waited once again for a reply and then I got one, one that almost threw me to the floor.
“Well, what we are doing and what we need to work on, is not giving too much information to the patient. It shouldn’t have been said that another medical manager is needed for approval. What should have been said was we are looking into it and we need more time for approval. That way the patient does not get as upset. So did you get you shots then?”
“Yeah. Not until I suffered for two more weeks on the floor.” I replied.
He just shook his head and lowered it and honestly to me seemed shocked over everything I told him.
By now I had I realized he was already well aware of the existence of all the things that infuriated me. He admitted they knew about processing errors. He admitted to the possibility of senior citizens being ripped off, and now instead of apologizing right away, he explained they need to train their employees not to reveal some of their policies. I was just stunned, I mean stunned.
My voice was gone at this point anyway and we were there for two hours, so I ended the meeting. We got up, he assured me he was taking all these notes back and reviewing them with everyone. I thanked him again for driving down and he left.
Dad and I stayed behind for a minute just shaking our heads in disbelief. I bet my dad that from here on out I would not have any trouble getting anything approved.
I came home to Amanda, who did not want to go since she worked there, and told her everything. She did not say anything, just shook her head like I did and held me. She could see how frustrated and exhausted I was. My pain level was off the charts from sitting there for over two hours. I took a few pills and went to lie down, hoping that I at least helped one person with the meeting I just had.
I have nothing really to say. It was that bad when you looked between the lines. Everyone was very cordial. He was very nice. No one’s temper rose to the point of being disrespectful. If you did not read between the lines you could actually say it was a great meeting, he listened to every word I had to say. It honestly scares me to know how many people are vulnerable to being ripped off, and how many people might not be getting the medical care that they need and could have.
I once again ask you to share this post. I want people to know that they need to fight for their medical care. That if they honestly believe they need a procedure or test, that they should appeal if they get denied. Do not let insurance companies or doctors dictate your care. Learn as much as you can about your ailment and dictate your care for yourself.
Thank you all for your continued support.