“Please understand that we are your health insurance plan – – we have special training in providing misinformation, acting incompetently, being argumentative and showing a complete lack of compassion or interest in your health. Now having said that . . . . . .How Can I Not Help You Today?”
Think Twice When Being Told ANYTHING By An Insurance Company
The ghouls and goblins don’t just knock on your door yelling “Trick Or Treat”! They sometimes reside in the so-called “Customer Service” departments of health insurers, proving on a daily basis that they are not interested in their Customers and not usually capable of providing Service. We thought some of these stories, and we have oodles of them, made for an appropriately ghastly Halloween blog. Make sure you read all the way to the end so you can see what the Devil has in store for some of these folks in the insurance industry!
“I don’t have to give you any information about your appeal!”
While this particular horror story involved an Aetna appeal years ago, problems like this happen all the time and we still can substitute the name of nearly every other major insurer for Aetna and have a similar tale to tell. Kelley was following up on an appeal we filed and was requesting confirmation that things were in process and inquiring about the status. The “Customer Service” person simply refused to provide any information despite confirming were the appealing patient’s representative. So what……she just wasn’t going to give any information to our office.
Many reading this will know how incredibly nice Kelley is. If you don’t know her then you can be certain her reputation for patience in matters like this is beyond dispute. Since this representative obviously wasn’t going to budge Kelley calmly requested to speak to a supervisor. That’s when things got interesting. The representative refused to transfer the call, stating the issue “did not rise to the level of involving a manager.”
A full thirty minutes later, after repeatedly demanding to speak with a supervisor and ultimately threatening to file a complaint with the Massachusetts Department of Insurance, Kelley was finally transferred to a Supervisor’s voicemail, who got an earful of “message” from our office concerning what occurred. Kelley suggested the Supervisor listen to the recording of her exchange with the service representative because (don’t forget) “this call may be recorded for quality assurance purposes.” When the Supervisor called Kelley back she profusely apologized and confirmed the customer service personnel are required to transfer the member to a supervisor immediately upon request and that the representative was way out of line. The happy ending to the story is ultimately that Aetna approved the RNY gastric bypass that was the subject of our appeal!
“I’m sorry but you don’t have any right to appeal or obtain an IRO of this denial.”
There are some insurers who try to eliminate patient rights to appeal, especially appeals occurring before the surgery takes place. Some denials are labeled as coming from “courtesy reviews” with no appeals available. (I personally find it interesting they use the term “courtesy review” when they rarely do much of a “review” and hardly ever show any “courtesy” . . . but I digress. . . .) BCBS of Alabama is among a number of payers who sometimes try to bar appeals. It is very rare that appeals are not available prior to having surgery so don’t just accept their statements as being true.
We know when they are playing games and most of the time companies (like BCBS of Alabama) end up processing the appeal and when (shock of shocks) they tell us the member appeal was denied, we request an “external review.” BCBS of Alabama, of course, has an unusually high level of incompetence so we should not have been shocked their response was that the member actually did not have external review available because the denial we received resulted from (you guessed it) a “courtesy review.” Unbelievable!
Enter Kelley (you’d think these companies would know better) who spoke to 2 different Supervisors about the situation, each of whom provided her with different (yet both still INCORRECT) stories about the nature of the member’s rights. After spending one hour and 10 minutes on the phoneKelley was finally transferred to an “Operations Manager” who was truly horrified at what occurred. She immediately initiated an expedited IRO request and 7 days later our client was approved! When the dust cleared Kelley and the Operations Manager had a conversation and she again apologized for all the misinformation which was conveyed and assured us that they were using this case as a “teaching example” for their customer service personnel.
“You didn’t think that just because weAPPROVEDyour surgery after your appeal we’re actually going toPAYfor it too, did you?!?”
It can be truly horrifying for the physician and facility to not get paid after successfully getting an approval. Worse still are patients like us who fear getting HUGE bills even though we thought everything was settled after “winning” a pre-surgery appeal. This can happen, usually when the maze of insurance company Departments fail to update their systems to show things were approved. We sometimes need to go back to a payer, even after a successful appeal, and re-start the battle. It can time time, patience and knowledge to successfully navigate the insurer’s system to get this fixed. Fortunately every time this happens we have gotten these claim denials resolved and re-processed for payment before the providers and patients turn into angry villagers storming Frankenstein’s castle to chase these Monsters for the payment they are due.
So as I wish everyone a safe and happy Halloween, I offer special greetings (and a warning) to insurance company executives and their customer service representatives who seemingly delight in making patients and providers miserable. They need to stop now. A number of years ago, at the Obesity Action Coalition’s first Your Weight Matters conference, my costume included a button warning those in the insurance industry who do not change their ways. . .Hopefully they listen!
Mrs. Lindstrom, Thank you for the great news.I will call my surgeon’s office to work out a schedule. I am grateful that they referred me to your office and I will recommend you to anyone who needs assistance.I believe that this result was achieved only through the advocacy of your firm. Thank you very much for all of your effort.
I am absolutely over the moon excited right now. I finished my 6 months supervised diet/nutrition with my surgeon’s office back in April, but I was denied when it was submitted to insurance, despite having a BMI of 42 and GERD (they denied it and said GERD wasn’t one of their approved co-morbidities, and my insurance plan requires a co-morbidity regardless of BMI). I immediately contacted Lindstrom Obesity Advocacy and began the appeals process with them. Within a month of them sending in my (wonderfully written) appeal letter, I just received a call to let me know that United has approved me for surgery and has provided their office with the approval and authorization number. . . . I am beyond excited! This is actually happening!!
Thank you so very much for this wonderful letter of request. I honestly regret not contacting you when I was initially denied. I am just flabbergasted at the detail and the evidence based references provided. WOW!!! I deeply regret not knowing you existed. You really take the WORD advocacy to a whole new MEANING. Words cannot describe how satisfied I am to see such documentation and how thankful I am for your help. Thank you!
OMG! I was NOT expecting this! I tried to call you when I received your message, but I think your office was already closed for the day. I will call back tomorrow just to say THANKS in person! Looks like Christmas came early! I will contact the doctor’s office tomorrow to schedule the surgery as quickly as possible…Words cannot express how thankful I am for your help! You have been such a pleasure to work with! I will make sure my surgeon and his office staff know how helpful you have been so they can be sure to recommend you to others that might be struggling with the same problem.
You are the best Thanks again for everything you did. I know for sure I never could have accomplished this on my own!
I just called my doctor’s office and the scheduler was absolutely amazed the denial got overturned! She said she has done tons of appeals for patients and it doesn’t ever usually work out this way. I can’t speak highly enough of Kelley and the Lindstrom group.
Dear Walter and Kelley: Today is the 1-year anniversary of my lap-band surgery. To date, I have lost 67 pounds and I am in the best shape of my life – I don’t remember a time that I weighed as little as I do now, not even in high school. The time you spent appealing my case was invaluable and absolutely life-changing for me, and I just want to let you know how very much I appreciate all the work you put into it on my behalf. I am thankful beyond words! God bless you!
Thank you so much Kelley (and Walter!). I so appreciate all you have done for me!!!
I’m so excited to finally be able to move on!
I just wanted to update you and let you know how much we appreciated your help in getting us this approval. My wife had the procedure done in October and has been doing great. Already she has lost weight and her sugar counts are stable and doing fine. The Doctor has taken her off Insulin and High Blood Pressure medicine as a result. She feels real good on the progress she made so far. Once again, thanks for all your help.
I was turned down by my insurance company because they said I was not fat enough for long enough. I hired the Lindstrom group and they were great. I was approved a week after they submitted my appeal….it was so worth it. They are the nicest people. I do not regret hiring them. I just wish I did it sooner.
After my initial denial by Cigna I hired Lindstrom Obesity Advocacy to handle my appeals and am happy to say that my denials were overturned on independent review. Kelley was wonderful, always available to me and always on top of the appeals at every turn. She kept me informed of any progress as soon as it developed. She really seems to care about her clients. I highly recommend using them. My first denial was in June and the denials were overturned in August on independent review. My surgeon’s office commented on how fast the process was compared to the experience of others in their office. . . . It was the best money I ever spent and I am over the moon that this worked out for me. My recommendation is don’t wait to contact them. I contacted them immediately after I got my first denial and they handled the rest. So that’s my two cents!