My Health Insurance Is Making Me Ill

Two weeks ago, I had a little phone time with some folks I throw a lot of money at every month. I was seeking reimbursements for some charges, and though I knew the people in charge had grounds to dispute them, I was confident that my status as a longtime, loyal customer would win the day. I called customer service with some trepidation, but quickly realized I had nothing to worry about. They reversed the snafu and wished me good day.

Sadly, I'm not talking about my health insurance company, CareFirst.

I'm talking about American Express and Banana Republic. In the first instance, American Express allowed me to reverse a plane ticket I'd bought in error. In the second, Banana Republic took off a late-payment charge for a credit card statement it had mailed to an old address. The companies both simply weighed giving me the benefit of the doubt against pushing me into the arms of a competitor, and chose wisely. Minutes later, I purchased the correct tickets from American Express, then started to fold down pages in Banana Republic's fall catalog.

My experience with my health insurance company has been altogether different. Recently, I was denied my reimbursement claim for the out-of-network care for my depression explicitly covered in my PPO plan, so I am appealing. I began the process by retrieving a complete history of my insurance company's reimbursement of my care from both my providers and CareFirst. I'll spare you the three-hour rundown. (Yup, it's a three-hour rundown, and I'm happy to send my detailed notes to anyone who'd like.) Suffice it to say, over the course of the morning, I was: put on hold 10 times; transferred without comment twice; told I had dental coverage (who knew?); schooled, poorly, in "Diagnostic and Statistical Manuals of Mental Disorders-IV" and the acronym DPI (or DIP?); hung up on once; told different information by every representative I spoke to; told to file a request; and now, at the bitter end, am allegedly going to receive two sets of documents that may or may not even contain the information I need.

(In fact, the only thing I got immediately and without difficulty were the notes of my entire treatment history from my past psychiatrist. Sure: my treatment history seems like it would be the central item of my appeal. But it's actually my billing history that I'm convinced will prove CareFirst is declining my treatment on indefensible grounds.)

A little background: for years, CareFirst covered my sessions with a psychiatrist and psychologist at a clinic that accepted insurance. Now, I'm seeing doctors with the exact same credentials, but they are out of network. Though my PPO plan explicitly states I am able to see any doctor I want and be covered, my claim has been denied with the Hal-like assertion that "benefits are not available for this kind of service when rendered by this type of provider." Right . . . except they were available when the "provider" -- that's a doctor, by the way -- had a business relationship with CareFirst.

Now I'm hunting down official billing records both from that clinic and CareFirst, preparing to file an appeal with both BlueCross BlueShield (does anyone just pick one name nowadays?) and the Maryland Insurance Administration, all to prove I deserve coverage their own Web site explains I already have. (At least I thought that's what "Freedom to visit any doctor or hospital outside of network; Members will just share more of the cost" means.)

Most of the health care debate has focused on getting the millions of uninsured Americans health care coverage. A worthy goal: except health care coverage is different from health care. And until the debate explains how we'll make sure those who have health insurance aren't forced to assemble 40-page dossiers simply to get reimbursed, we're not having a conversation at all.

Earlier, Lynn Sweet wrote in this space about our president's use of the tale of Otto Raddatz, who supposedly died after his insurance company denied him care for his treatment for his cancer. As Sweet explains, in the real story, Raddatz actually only lost his coverage for a few weeks. Apparently, after negotiations with the state attorney general's office and intense lobbying by his sister, an attorney, Raddatz's care was reinstated. Long story short: he died six years later of cancer.

Sweet makes the argument that Obama should drop the debunked story from his repertoire. But as far as I'm concerned, Obama doesn't tell this story enough. Because the interesting part of story isn't that Raddatz didn't die because his insurance denied him care. It's that Raddatz couldn't get the care he needed without the aid of the Illinois attorney general.

Obama has spoken of watching his mother spend her last days pushing papers around, anguished about whether her insurance would cover her care. But I've yet to hear him or anyone explain what new forces -- market, regulatory, or otherwise -- will prevent insurance companies from engaging in the kind of routine chicanery that keeps stockholders satisfied and me on the line.

In my last conversation of the day, my second CareFirst representative (the first had hung up on me) assured me that I'd have my coverage history from them in seven to 14 days.

"Really?" I said. "Because I only have 60 days to file this appeal."

"Well, we could get it tomorrow," she said. "You never know."

You never know. It was a strangely fitting end to my first day on the job. Because it's true: You never know if they'll pick up the phone. You never know who has the right piece of information when they do. You never know what's in your file, or if you can even get it. You never know how far it goes back. You never know how long it will take to get. You never know if the codes will match, and you never know why the person declining your reimbursement made the decision in the first place.

Most important: in the case of insurance companies, you never know if you'll get what you pay for.

Update:

This week, I called CareFirst's press representative to get his thoughts on my above-described experience getting information. I told him that, since I'd begun seeing my therapist months ago, I'd been: unable to get a confirmation that my PPO would cover care; unable to get a clear answer on where to submit my out-of-state claim; hung up on when I'd tried to get a coverage history sent to me; told my records went back to three different years; and, most important, been given no answer on why my claim had been rejected, but was told I could file an official appeal.

First, he told me I'd have to sign a waiver so that he could review my file. "Really?" I said. "I have to sign a waiver for you to see my medical history for you to give me a comment on what I've told you?"

"Well, they're linked," he said.

"I find it hard to believe that CareFirst has no way to look at my customer service history without seeing my entire medical history," I said. "I'm not giving you access to my medical history so you can comment on a piece."

His response: "Well, it wouldn't be reviewed by me. It would be reviewed by executive Inquiry" -- apparently the entity that oversees Member Services -- which I confirmed actually meant customer service. By that time, my head was spinning.

"And so the people who oversee Member Services would be reviewing my entire medical history?" I said.

"Well, no," he said. "I'd give them your address and member number, and they'd review your customer service experience."

I asked him if he would be willing to sign something to that effect.

He paused. "You could send me an e-mail," he said. "It's a pretty stock form."

Minutes later, I received the form by e-mail:

Please find the enclosed release form for the purpose of responding to your inquiry. We will need the form signed and returned in order to comment on anything specific to your case.

WHEREAS, Member is desirous in cooperating and allowing for public disclosure and use by the news media (hereinafter "Media") in an open and public forum, all mailers relating to Member's membership, participation, benefits, services, and all related mailers.

NOW THEREFORE, the premises considered, the undersigned hereby authorizes, release and consents to the release of any and all medical information and/or reports (including, but not limited to, medical charts, x-rays, diagnosis, treatment, statements to physicians or other providers of care, payments, benefits, psychiatric services or benefits, any and all other such related information), health insurance or health plan coverage, benefits, payments, services and any other such information whatsoever, and this Authorization and Consent is given without restriction or limitation.

FURTHER, the undersigned for himself or herself, and his or her heirs, personal representatives, custodians, and guardians, hereby releases, forgives, and forever discharges CareFirst and/or its subsidiaries, directors, officers, agents, employees, servants, successors and assigns, from any and all obligation or liability whatsoever in connection with the use, exhibition, publication or republication, of said material or Media comments.

I'm not a lawyer -- increasingly I wish I were -- but I'm pretty sure that says if I want a comment on my case, not only can CareFirst review my file, they can do anything they want with it, including release it to the media.

I think I'll take "no comment."