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Your Reports of Shameful Acts by Insurance Companies
 
     
 
"All I want is the truth. Just gimme some truth."     ...J. Lennon
 
     
  Rate The Insurer is looking for reports of your worst nightmare interactions with insurance companies.  Patient benefits delayed, coverage denied, lies told to you by "case managers,"  intrusions into the doctor/patient relationship, claims "lost" and unpaid, we'll report it!  Send your stories to RTI Wall Of Shame and we'll make sure they get posted.  

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Insurance Company Nonpayment

Russ Holstein, PhD reports: "I have been corresponding with Horizon Blue Cross/Blue Shield of New Jersey and their payer, Magellan, about this issue for two years. All agree that I should be paid for services I provided to a patient that go back to June 2001. They refused to pay although the patient had a parity benefit. Nobody at Horizon or Magellan argues that the services should not be paid for. They simply do not pay. I have written to the state of New Jersey Insurance Commissioner and their policy is to tell me to contact the New Jersey Psychological Association who will document the poor claims paying record of these companies. None of this results in the provider being reimbursed, or the patient's benefits being paid according to their insurance contract."

19 May 2004: Dr. Holstein reports: A patient with a benefit through the Hospital network where she works came in with an unusual benefit. The hospital network is Solaris (JFK Medical Center in Edison, NJ and Muhlenberg Hospital in Plainfield, NJ). Services provided by doctors in the Solaris network are reimbursed at 100%. As we are over 35 miles away from the closer of these hospitals, we are not in the network. The benefit also covers participating Horizon Blue Cross/Blue Shield of New Jersey PPO with a $30.00 copay. Services were provided by my wife in October and November, 2003. Blue Cross/Blue Shield considered the claim in February and May, 2004, refusing to pay. Finally, I was told that the benefit had been switched to another network, QualCare, on Jan 1, 2004, well after my wife's services had been rendered. Blue Cross/ Blue Shield told us to call the benefit manager, Solaris, who told us to call QualCare. QualCare indicated that they would pay the claim if my wife was in their network (She resigned early in 2003). I told them that they could pay our BC/BS PPO rate, and they said no, only the QualCare rate but we "had better be in their network." After several more calls, the best advice BC/BS could offer is to submit the claim directly to Solaris, the patient's employer! Do they have any idea of the HIPAA and privacy implications of this suggestion? There is no way to get this claim paid. The NJ Insurance Commissioner won't touch it because it's and ERISA plan.

RTI NOTE:  Insurance companies can simply "lose" claims, refuse to pay them on a whim, or request more information, for an extended period of time.  Virtually all health professionals have had this experience at one time or another.  In 1999, an independent review reported by the American Psychological Association found that if even one percent of reimbursements were delayed for about a year, the insurance industry would generate $280 million in interest for itself (see 280 million reasons to deny care).

Insurance Company Inaccurate Listing of Practitioner

May 11 2004: Russ Holstein also reports: In the Fall of 2002, a patient of my wife's was offered a new health benefit at her new job. She had a plan through Cobra and could have continued with this, but she checked the book for the list of network providers of the new plan. In the book, she found my wife's name. This was the brand new book (Fall Winter, 2002-2003) published for the managed care benefit of Horizon (New Jersey) Blue Cross/Blue Shield. On page 584 the patient found under the listing of my name a second listing with my and my wife's name included. Finding her psychologist in the book, she signed up for the benefit. Unfortunately, my wife, Barbara Holstein, Ed.D., was never in this network which is a Magellan network. Magellan offered to "ad hoc" my wife if she would work for the the rate of $68.00 per 90806. She did not agree. So the patient has to be responsible for the first $2500 of out of network before the benefit pays one red cent. Because of the patient's financial status it is unlikely the patient can afford any "out of pocket" expenses. Horizon Blue/Cross Blue Shield has taken no responsibility for putting my wife's name in the book, claiming that my participation is through our practice and that her name appeared in capital letters as part of the name of the group practice and was in no way indicative of her participation in the plan. Because of the insurance company's improper listing of the practitioner, the patient made the reasonable assumption that benefits were available, resulting in financial damage to the practitioner and, potentially, to the patient. The insurance company has taken no responsibility and made no effort to correct for the inaccurate listing.

Insurance Company Refuses to Disclose
How Much It Will Reimburse

6 May 2004: Dr. Elliot Zelevansky reports: Dear Colleagues, I am writing to summarize an incident with UnitedHealthcare for your suggestions and to provide an alert to pursue this via such channels as may be appropriate. I was contacted by a family seeking help for their son, who is a cancer survivor and who was seen at the local MH clinic, started on medications for depression, but who did not form a working relationship with the therapist at the clinic. In order to assist the family in being fully informed as to their net costs for my services, I had them provide me with a copy of their insurance card. While the mother was sure her benefits were "good," I wanted to check so that there would be clarity as to what might be reimbursed and what the balance might be. As it turns out, the family's plan through the father's employer is -- perhaps-- a "good" one. For Out-of-network, Out-Patient Mental Health services, the family has unlimited visits per calendar year, after they meet an individual out-of-pocket deductible of $ 200 per person, which deductible can be combined with regular medical expenses. Thereafter, the family must pay a 20% co-pay per session and the insurer pays 80% of the ..... "Usual and Customary Rate (UCR)." Ergo, for the family to know how much that amounts to in actual benefits they will receive, they need to know the UCR. Of course, I was ready to provide both the anticipated CPT codes and the zip code of my practice where the services would be provided, but the insurer adamantly refused and maintained that they were not able to provide the UCR amount.

After the better part of an hour, over two days, after being put on hold, dropped (accidentally I'm sure) into the very beginning of the phone queue, twice, after speaking with Franco, Tabitha, Connie ("We're not allowed to give our last names"), and having Connie collect my name, tax ID#, the patient name, CPT & zip codes (again), I was told that they were unable to give the UCR amount "due to HIPAA." This is obviously ridiculous. How could their payment rate, supposedly "usual and customary" predicated on the rates charged for service codes in a given geographic area, be "Protected Health Information?"

After more time on hold, Connie, reluctantly, passed me on to her supervisor, Janice, who heard my whole tale yet again, did not blame HIPAA and merely said she was powerless to respond with the UCR information due to "company policy." At my insistence, I got the name of her manager, Alicia, who was in Texas. I also got her number, fortunately, because when Janice transferred me, I got their customer satisfaction survey, which I dutifully completed. When I called back, Alicia was away until next Monday. So, I left a message, with not a lot of confidence that the call would be returned.

I am raising this issue because I want some insurance commission to take some action, as I deem this an unfair and deceitful business practice. This family essentially is being blocked from knowing what their costs and what their benefits will be, for an insurance policy they purchase through their employer. I want to help them, but I do not want them to be surprised when my bill reflects that their insurer has paid them 80% of a low-ball number. They deserve to be as fully informed about their obligations, and I have an ethical responsibility to do so.

Insurance Company Provides Inaccurate Information on I.D. Card And in Benefits Book

11 May 2004: Dr. Holstein reports: In 2003 my wife resigned from all of her Blue Cross/ Blue Shield contracts (she had been in the Horizon PPO). Last Sept. she saw a 6 year old along with his family. The family presented with a Horizon Blue Card PPO benefit. Blue Cross/Blue Shied in New Jersey utilizes a passive PPO which means that if the patient uses in-network professionals, they would get the network discount. Out of network-no discount. On the ID card it spelled out, MENTAL HEALTH & SUBSTANCE ABUSE SERVICES: For mental health or alcohol/substance abuse admissions you must call the Health Management Center's 24 hour confidential Help Line at 1-800-624-6864. Since by this language, Horizon means inpatient services are managed, she did not call the help line for outpatient treatment of her young patient. However, since most of the claims have been unpaid, I called to find out that the manager of care, Health Management Center, a subsidiary of Managed Health Network, really manages both inpatient and outpatient mental health. The information on the card was just plain wrong: the benefit card indicated that mental health and substance abuse inpatient (admissions) were managed but outpatient was secretly managed as well. Furthermore, in the benefits book the patient's father was issued, the managment of care was attributed to a company that was bankrupt one year before the benefit was issued, and the provider directory had the wrong list of providers. It had Horizon Blue Cross/Blue Shield's mental health provider list rather than the HCM-MHN list. So far, nobody wants to take responsibility, apologize or most importantly, pay for the services rendered. Nobody returns calls in this matter. Additionally, the plan is a union benefit and the union has been of no help. It is an ERISA plan under which, I am told, there is no recourse when misinformation appears on a benefit card.

Benefit Payments Subsequently Withheld ("Recouped")
From Other Patients

19 May 2004 update in this case: The plan did pay for some of the early services. Today the services that were supplied by my wife and paid by Blue Cross/ Blue Shield (they contend in error) have been "charged back." I received an EOB refusing payment owed FOR ANOTHER PATIENT because they are taking back the payments for this patient. They will also deny payment for several subsequent patients as they are taking over $500.00 back.

Excessive Delay in Credentialing Practitioner

12 May 2004, Rodney Timbrook, PhD reports: My application to the ValueOptions provider panel took "only" 18 months to process. During those 18 months I was forced to resubmit many items in the application.

Discrimination Against Independently Licensed Practitioner, Requiring "Supervision"
Not Required by Law

Dr. Timbrook also reports: I applied to a local HMO, Physician's Health Plan of Indiana, but was denied admission to the panel because I was not under the supervision of a psychiatrist. After a repeated exchange with the Medical Director, my application was finally denied when I refused to be under anyone's supervision to provide clinical services. I filed a complain with the Indiana Insurance Commission, who investigated the complaint but acquiesced to the HMO's explanation that they simply did not have a business need for more providers, despite all the documentation I provided about the true reason my application was being declined. Interestingly enough, I recently was approved to be on the panel, after I joined one of the two or three psychology practices that have been independent providers on their panel since the company was formed.

 
     
     

The fine print:  Rate The Insurer is not able to verify and makes no representations about the accuracy of the reports posted here.  The person providing the report is responsible for accuracy and for the consequences of defamation and libel.  However, RTI doubts it really is possible to "defame" health insurance companies, and that "infamy" and "health insurance company" are synonyms.  Given the way health insurance companies routinely abuse consumers and professionals, there really is no need for false or exaggerated reports.

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