“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!
This made my life. Literally. I cannot begin to thank you enough for your expert help in having this over turned for me. I know without your help, it wouldnt have been possible. My surgeon has me scheduled for surgery on Feb 6. I will be sure to stay in touch and let you know how it all goes. I have a lot of hope that I will be able to come off of my insulin pump and have better control with just a few injections. I truly believe this is possible for me, and that my quality of life will be so much better. The work you have done is going to change so much for me. I plan, in turn, to make a difference for many others. Its a pretty great ripple effect, isnt it?
I hired them for my appeal. They were great and I was approved a week after submission and my case was not an easy win. I was a revision case and Walter’s appeal letter brought tears to my eyes.
Walter and Kelley,
1 year ago today I had surgery with Dr. Alok Gandhi at Rochester general hospital. I am happy to report that I have lost 120 lbs., off all of my medicine and cpap machine. I take vitamin supplements but everything else is gone. I just wanted to thank you again for your help with CIGNA and wish you both a great day and a very heartfelt “Thank You”.
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.
Wishing you and Walter a GREAT 2015 also. You both gave me the tool I needed to get my life back – without the both of you (and your AMAZING team) working on my case I cannot say that I would be where I am today. I APPRECIATE all you did and continue to do for people like me. I continue to spread the word about your advocacy group and all you can help other accomplish if they only make that first call or send that first email like I did. I hope others I have talked to have taken advantage of the help and guidance you can provide. I will sing your praises to anyone who will listen – especially if they have a denial for surgery.
Oh my goodness!!!! Kelley – I can’t say thank you enough!!!! Thank you, thank you, thank you!!!! This is the BEST news ever. I am SO HAPPY! Thank you! Please tell me where/how I can leave you a review. Both you and Mr. Lindstrom went so above and beyond my highest hopes. I am so incredibly thankful. You guys are the best! Calling now to schedule the surgery!!!
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!!
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.
I had to go to external review but I’m now APPROVED for revision from Band to RNY!!!! I can’t say enough positive things about Kelley & Walter at Lindstrom Obesity Advocacy. If you find yourself stuck with denials from insurance companies, I highly recommend them!
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.