One such encounter went like this:
Me: “Hi. I’m calling about my daughter’s ambulance and hospital charges. I haven’t been able to reach my grievance coordinator about the appeal.”
Representative: “I can help you.”
**Me: **(Genuinely excited.) “Great!”
Representative: “Oh, I see your daughter turned 18. I can’t discuss her information with you.”
Me: “I sent a release of information form by mail, fax and email. I also faxed our conservatorship papers.”
Representative: “I’m sorry, it’s not on file. What office did you send it to?”
Me: (I give the information.)
Representative: “That’s the wrong fax number. Let me give you the correct one.”
Me: “I’m not inventing numbers out of the ether. This is the third new fax number I’ve been given. Are the address and email inaccurate too?”
Representative: “I’m sorry, but I can’t discuss your daughter’s claims with you without this information. Can you put her on the phone to give verbal consent?”
**Me: **“I can’t put her on the phone. She’s currently in a treatment center and has no access to a phone, which is why I have a conservatorship to help with her medical care.”
Representative: “I’m sorry, ma’am. There’s nothing I can do without the forms or her verbal consent.”
Me: “Who do you think pays the insurance premium and all her providers? I’m just trying to settle her claims, and I don’t know what we owe without access.”
Representative: “I can only answer general questions.”
Me: “OK. From the bills I’ve received, we’re being charged out-of-network fees for the ambulance, ER, ER doctor and hospital.”
Representative: “Was this out of state?”
**Me: **“Yes.”
Representative: “Hang on, I have to transfer you.”
I was on hold for another 15 minutes, and then got cut off. I called back, was transferred twice and then repeated a version of the above conversation before resuming — with a grievance coordinator!
Grievance coordinator: “The ambulance and ER facility were both out of state and out of network.”
Me: “A treatment center called for an ambulance. I wasn’t given a choice of who responded or where they took her.”
Grievance coordinator: “They used out-of-network providers.”
Me: “They dialed 911. No one stops to ask the closest ambulance what their network status is.”
Grievance coordinator: “They did transfer her to an in-network hospital, but the physicians were not participating providers.”
**Me: **“Under the No Surprises Act, insurance must cover all providers in the case of an emergency, whether they are in network or not — even if out of state.”
(There was a long silence.)
Me: “Are you still there?”
Grievance coordinator: “Yes, ma’am. Once you get the conservatorship papers to us, we can look at those claims. Is there anything else I can help you with?”
Me: “Apparently not.”
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It's the majority of them, but there are exceptions. I switched to Blue Shield (not Blue Cross or one of the combined companies in some states) and had almost zero problems. They paid my claims accurately the vast majority of the time and fixed the occasional problem with relatively little fuss. The Blue Shield reps also knew their stuff and I never once had to explain my policy to them.
Health Net is deliberately designed from the bottom up to refuse legitimate claims and to fight tooth and nail when customers demand they follow their own contract. IMO Health Net should be shut down.
I had to do the same, despite recovering from surgery. To make matters worse, after I hit the maximum out of pocket amount the medical centers continued to send bills showing I owed a balance. It took nearly a year and repeated escalation to their executive and legal departments to get them to provide refunds. Calls, faxes and certified letters were completely ignored.
Corporate America has become quasi-legal and well-funded organized crime.
Yup, we always hit our deductible within about 2-3 months due to my kid's therapy, yet we still get full bills from all of our providers even though we should be 90-100% covered at that point. You call the insurance, they say the provider billed it wrong, you call the provider's office and they refuse that they did anything wrong and tell you to call your insurance. It's a never ending cycle.
The worst of the medical centers that knowingly overcharged me was USC Keck in L.A. They completely ignored calls, emails, faxes and certified letters for nearly a year - never once responding to anything. The scumbags actually sent my account to collections despite my having a zero balance because they flatly refused to credit my overpayments. I've learned to refuse payment of any medical bill before making absolutely sure I owe the company what they are billing, and that can take months.
The thing that amazes me with all of these companies is they expect you and I to be right on top of our accounts, respond to letters and calls, and pay their bills within 30 days. This despite the fact they don't give a fuck about doing the same. My attitude has become the same as theirs: "fuck 'em, let them wait". I get sternly worded bills with red "Past Due" printed on them every month, ignore them completely and pay when I'm ready. There's been no downside.