With Health Insurance, It's Always Your Fault

This particular case really is not the insurance company's fault, or the doctor's . . . it's yours. For not looking into things beforehand.


Brief history: since September, I've been writing about the process of getting my insurer to reimburse me for out-of-network claims for therapy for my depression. (Click links for earlier dispatches on the labyrinth of claim denial, mental health's market value, the Kafka-esque loop of customer service, and how I got reimbursed through a cough.)

Recently, I had an unexpected success: CareFirst reversed its denial of my original claim and paid it, and partially reimbursed me for all my claims submitted thereafter. My first instinct, of course, was to revel in my triumph. This lasted about 2 seconds. The second was to look closely for the worm in the bud.

There was something curious, after all, about the checks themselves. One lone check in its own envelope reimbursed the first claim I submitted at 70 percent of the allowed amount, which is actually 5 percent more than my policy owes me. In a handy "remark R008" appending, it informed me that the previous rejection for the first claim was incorrect, and I had now been reimbursed correctly. But the next set of checks, for a bunch of later claims, paid all the other claims with a 50 percent benefit reduction, informing me (hello, remark GAB7!) that because I'd failed to obtain prior authorization for "specified services," my benefits had been reduced.

And, battle-weary, I almost let it go.

In our bootstrap culture, the instinct to assume responsibility for things that are absolutely out of one's control is strong. (Use the Fault, Luke!) Yes, CareFirst had docked me 50 percent for something it said I had failed to do: obtain prior authorization. Well, actually, I had called to get prior authorization, and been told I didn't need it. But maybe I had messed up, misread the addendum to paragraph 3, item A in the third rider. And if so, the last thing I wanted to do was spend three more months finding it out.

Also, here was a check in my hand. As any flight attendant charged with handing out hotel vouchers and free RC Cola at a canceled flight knows, most of us are less interested in being paid exactly what we're owed than in feeling at least we haven't been taken advantage of. After all, what customer doesn't like to feel a little magnanimous instead of incredibly furious? And look, here was CareFirst, smiling, meeting me halfway! They'd even split my benefits 50-50 down the middle, each of us acknowledging our mutual responsibility. What could be simpler?

But I couldn't quite forget that CareFirst was the company that would not go on the record with me about this series of columns unless I first signed a waiver allowing it to make my entire medical record public, which I refuse to do. (When I again called CareFirst's spokesperson to comment on the events in this column and to provide me the means to get prior authorization, the spokesperson repeated I'd have to sign a waiver -- then sent me a paragraph from my member handbook that instructed me to call the number on the back of my card.) Here too, the company's tone made it clear it was primed to escalate its argument at the first sign of insubordination. "Our payment represents the maximum benefits available for this service," it informed me ominously. Translation: Don't even think about trying anything funny.

But I was, I was! Because I'd seen my Pavlovian response -- admit fault, cash the check, let it go -- mirrored in my friends and family too many times. Just that week, two friends told me that they'd paid in full for charges added by the doctor that the insurance had refused to cover, events in which an unscrupulous doctor and the insurance company seemed to benefit at the expense of the patient. And years ago, my insurer at the time had filed claims in ever-increasing increments, each time producing a fascinating new reason why I couldn't quite receive whatever payout the policy specified. (My favorite was reimbursing my drugs at 50 percent, since drugs for depression apparently are therapy.) Had my current insurer simply refused to relent -- and handed me some RC Cola with a tired smile -- I would have known they were at least on the up and up. It was the haphazard volley of rejection -- refuse claim, cite inscrutable cause, ignore claim entirely -- that made me certain it was an extraordinarily successful profit-making trinity.

Now, as I looked closer at CareFirst, the company's arguments for only partially reimbursing me became even harder to follow. After all, how could CareFirst dock me for not obtaining prior authorization on most of the claims when it had paid the first one at the rate specified by my policy? (Dear, sweet Remark R008 even genteelly observed the company had previously been mistaken to deny it outright.) I looked at the second set of claims -- and there was the original one again, now filled at a 50 percent reduction. By my count, this meant they'd taken one claim and denied it, then reimbursed it correctly, then reimbursed it at 50 percent. One week later, my doctor handed me paperwork CareFirst had sent to her indicating it had denied everything. This was a company that was capable of producing six pages of paperwork and four separate codes to split one claim for $200 into its component parts. Couldn't it manage to figure out it had already filled the claim three times?

Well, yes -- but it's fiscally advantageous to not even bother. Denying claims haphazardly and keeping chaotic records still puts the onus on the consumer to not only keep track of claims but also launch an argument as to why she's owed at all. When the company can't even be trusted to pick up the phone, and the address to file an appeal is a P.O. box, who can be blamed for keeping the bird in hand?

Unfortunately for CareFirst, I am a spiteful consumer who once filed a complaint with the state against Verizon for a $79.98 overcharge, just because I couldn't see why I should ever give Verizon anything. If CareFirst and I were splitting our debt down the middle, I couldn't see why they shouldn't also join me in being forced to make a case for their decision.

For months, I'd been putting off filing a complaint with the Maryland Insurance Administration, believing against all available data that if I could just have one more leetle conversation with CareFirst, one teeny chat, someone there would, for a change, not transfer me, put me on hold, hang up on me outright, tell me they didn't know, tell me exactly the opposite of what the last person had told me, or tell me they knew but couldn't tell me and the person who could tell me was not available by phone -- but instead would enthusiastically agree with me on the egregious misreading of my policy and send me a check for the exact amount I am actually owed. All subsequent claims would receive timely reimbursements with the same pleasant reaction and attention to detail, and we would go our way, one industry, under God, underwriteable, with liberty and co-pays for all.

Five months of wrangling had made it clear this was not going to happen. But I had still not shaken off the nagging worry that maybe this was all about something I'd done. (See my helpful commenter, above.) I was going to give them one last chance to tell me exactly why I didn't deserve my own money.

Since CareFirst claimed I hadn't gotten prior authorization to go out of network, my first task was to see how one does get prior authorization. (Never mind the whole point of paying for a PPO is that you don't have to get prior authorization.) When I returned to therapy in the spring, I'd called CareFirst and asked exactly that. I'd was hung up on, transferred, told "I don't know, actually" twice, transferred again, told to call Magellan, the company that provides in-network services for CareFirst's mental health clients; and to call New York's Empire Plan, New York State's Health Insurance Program, since New York is where my treatment would be. Empire's response was my favorite: When a prompt directed me to confirm if I had my insurance with Empire, I pressed "no." A cool mechanical voice told me to hang up and call my insurer. Goodbye!

A close reading of an online handbook indicated I should call the Mental Health number on the back of my card. I knew it would only direct me to Magellan. No matter. Maybe I had been wrong. And at first, it seemed so. Was Magellan, I asked a nice young man at the other end of the line, the one who could approve my out-of-network care?

"Oh, yes!" he responded, and immediately e-mailed me a form. Despite my annoyance, I felt relief. It had been me! What did I do? It was easy, he said. All my doctor would have to do is submit a request, and he would work with CareFirst to make sure my benefits were replaced.

Except the Member Services representative for CareFirst I called immediately thereafter seemed to think differently. "Well, this is out-of-network care," she said deliberately. "Magellan would have no say-so at all." No say-so, you say. Who would? "Call Utilization Management," she said. "That penalty will be removed and paid at the correct rate."

I called Utilization Management, CareFirst's polite name for the department where you ask if you can get treatment and they tell you no. There, the representative seemed almost taken aback by my request. "We don't handle Mental Health!" she said. "We don't handle any Mental Health whatsoever." Okay, keep your shirt on! So what should I do? "I have someone at Magellan," she said smoothly. "Her name is Angela." Before I could stop her, she'd switched off the line and transferred me . . .

. . . to Member Services.

That night, I typed a four-page roundup of my experience with CareFirst. I filled out the Maryland Insurance Administration's Appeal and Grievance form. I made a neat stack of all of my supporting documents, took it to the copy shop across town, and spent one hour collating the copies correctly and placing sticky notes where I thought they'd help. Then I placed them in an envelope and mailed them to Maryland, feeling a mixture of dread, trepidation, annoyance, satisfaction, and outrage.

But one thing I no longer felt was guilt.