Tuesday, July 29, 2014

Conveniently Incompetent

When I last updated you on my overhead lift system reimbursement from Anthem, I wrote: “My insurance company indicated they will reimburse all but $700 of the $12,000 product cost. I haven’t seen that check yet, and I won’t believe it until I do.”

I was told by Anthem that all I had to do was submit a one-page claim form, and I would get my check. That’s a funny one.

Just for good measure, when I sent in the claim form I also sent the quotes I had received for the product, the invoices I had received for the product, and a letter from Anthem indicating that the product was preapproved, and at the higher in-network reimbursement rate.

Weeks went by and I heard nothing. I checked their website frequently until one day I saw that my claim had been denied. I was annoyed, but not completely surprised. I assumed there was more paperwork that they would need. So I called them and asked why my claim had been denied.

“The product you purchased is not medically necessary.”

“I am holding a letter from you dated June 6 that says the product is medically necessary, and that I will be reimbursed at the in-network rate.”

“Can I put you on hold?”

“Yes you can.”

About 10 minutes went by.

“It appears you are correct. The claim should not have been denied. I will put it back through the system and you should hear from us in 7 to 10 days.”

In about 10 days I saw online that the claim had been approved. The next day I received a rejection letter via snail mail that I knew was obsolete. But the interesting thing was their reason for denial.

“Our in-house physician has examined this claim and determined that it is for an experimental product. Anthem does not reimburse for experimental products.”

This was an entirely different, yet equally invalid reason for denying my claim.

About a week later I received full payment for the overhead lift system, cashed the check, and paid off my credit card. All is well that ends well.

I posted about this fiasco on Facebook, and I received many comments along the lines of, “That’s how they operate. They deny, deny, deny, and only if you are persistent do you beat them. It’s their modus operandi – their standard operating procedure. They hope you give up before they have to pay.”

I don’t think this is true, exactly. I can’t believe that managers and employees have staff meetings and training sessions where they teach the fine art of deception and lying. These are professional organizations and presumably decent human beings. Yet, it sure looks like they throw roadblocks up just hoping that you’ll trip on one of them, or give up altogether.

What we have here is an organization being conveniently incompetent.

I think they choose not to invest in training their claim processing personnel to be as competent and efficient as they could be, and make little effort to provide them with state-of-the-art claims management software. There would be meager return on that investment. Patients are not their customers, in the normal sense. The insurance company’s customers are the organizations who purchase their group policies. Most of these organizations make their purchasing decisions based on cost and coverage, with little regard given to claim processing service. So, if investing in better service doesn’t win them more business or in any way contribute to the bottom line, management in these organizations seems content with poorly trained personnel who tend to make copious errors, predominately in favor of the insurance company.

That’s how I think these things work. What do you think?


  1. Mitch,
    I have been told by a customer service rep that at that company, the first tier people you talk to are NOT ALLOWED TO APPROVE CHANGES!!! Their main job is to simply give you the information you've already received and get you off the phone. You as the insured have to specifically ask for the problem to be escalated to the next level. And even then, it will only happen after the person at that level reads the comments of the first tier servicer and deems that you may have a case.

    I have to have blood tests every 3 months. My insurance changed where I have to go to have the tests done. But every time I have the tests, that same insurance denies the payment for the pathology reading of those same tests. I have now learned that A) I have to call the insurance company each time this occurs. And B) I MUST time that call so that the payment to the lab HAS been processed and the payment to the pathologist HAS been denied. Apparently there is nothing that the pathologist's billing company nor the insurance can do to overcome this strange and convoluted process. Because if I don't do all this then I AM THE ONE REQUIRED TO PAY THE BILL!

  2. Mitch, congrats and I agree entirely...companies' customer service reps are "conveniently imcompetent" and portly trained. This holds true for some Medicare, private long term disability companies, and probably dEntal insurance companies as well. As for us, and the other multitudes, we just have to craft our own skills and receive what we are entitled to, and indeed, really need. Toni in Oregon. :-)

  3. My dissertation is about why corporate and in-house training fails. This scenario and your observations are indeed atypical of inadequately trained or poorly developed and delivered in-house training. I am sorry that you had to endure this entire episode, my friend.

  4. I know a couple of those people and must say that many are smart and compassionate and are doing what they are told to do. If they can stomach it while they are new enough, they eventually rise to the level of being able to approve claims. I think they put their newest people on the front lines so they only know to parrot their training. I know there are people who deal with insurance companies for a living and you can see why that makes them a living!

  5. I believe that these companies should have a disabled person on their staff. If the rest of the group could view things through his/her eyes, there wouldn't be so many problems. Unfortunately, they may lose money with such a practice. So, it's better to screw the customer and rake in the bucks.

  6. What I first thought of when I read your blog was a 60 Minute (CBS) report a few years back. They interviewed ex-empoyees (whistleblowers) of an insurance company who spoke freely about being required to deny or close a percentage of their claims.
    I'm afraid profit is the bottom line, not compassion, ethics or having a disabled person on staff to create perspective. It is a top-down policy (highy paid executives salaries based on profits) and not likely to change any time soon.

  7. Mitch, I think you're being much too charitable in your assessment of the "Convenient Incompetence" of the insurance company drones. I'm generally a very even-tempered guy, slow to anger, but 10 minutes on the phone with the insurance demons has me almost invariably spitting blood. It's abundantly clear that these people's directive is to wear you down, and make it so difficult to get any kind of satisfaction, much less payment, that you will finally just quit trying. I wish I could have all the hours back that I've spent going around in circles with insurance company reps who blatantly hand out misinformation time and time again. Better stop here, I feel a real rant coming on…

  8. Mary Ellen, what a horrible situation for you. You might be able to contact your state insurance board to complain, but they probably have so many complaints it will take them forever to get back to you!

    Toni, unfortunately you are correct. The responsibility falls on us to essentially do the insurance company's job for them – to defend our own rights per their contract with us.

    anonymous, can you send me a link to your dissertation? I would love to read it. email@enjoyingtheride.com

    Daphne, that is my assumption – the people on the front lines are not to blame, and I try to treat them with respect for that reason.

    Muffie, I like your idea!

    Unknown, I didn't see that 60 Minutes report, but I'm not surprised. As long as there is money to be made by denying legitimate claims, companies will deny legitimate claims.

    Marc, you're not the only one to accuse me of being too kind. A lawyer friend of mine who has prosecuted insurance companies for these types of problems sent me a scathing email! That's just how I operate, however. I assume that people's motives are genuine, but I remain persistent in my demands. I further assume these front-line people are prevented from doing what they know is right by poor systems or corrupt senior managers. Actually, my experience has been that Anthem makes errors both in my favor and against me. They have approved two major claims in the past that they really shouldn't have if they had read their own contract more carefully. That's how, with my personal experience, I arrived at the "convenient incompetence" conclusion. Your frustration is very common and understandable, probably even justified,as it is with anyone who has a chronic disease and must deal with these people on a frequent basis.

  9. I had a problem recently with Independent Blue Cross (IBX). They would say yes, you are due a refund, but then I would check and it was denied, and this went back and forth for months. Finally I emailed Jim Donovan at CBS 3 (Philadelphia). He fights for people's rights with all sorts of companies. Within a few days of communicating with him I got my refund via UPS overnight.

    If you have something like that on one of your news channels, I suggest you contact the.

  10. I was refused payment for medical on an auto accident claim. I wrote the state insurance commissioner, president of AARP and the CEO of Hartford auto insurance on a friday. They approved and sent a check on Monday.

  11. anonymous and anonymous, it's great that there are people and organizations who can give assistance, but it's too bad they are necessary at all. kudos to both of you for your persistence!