Woven through out this story of my daughter, her epilepsy, mental illness, and all of the accompanying events, is health insurance.
This week, after having submitting paperwork over nine months ago to Medi-Cal (the State of California’s health coverage for the disabled or impoverished) I was told three weeks ago that my claims was complete and correct.
Medi-Cal was now going to rush my claim through because they had totaled the costs and realized that it was a substantial amount of money, the check should be sent out in just a few more weeks.
This claim was only a portion of the costs of my daughters treatment last year and I desperately need to recover some of this since the charges were more than I had.
The letter arrived … claim denied!
I called the woman from County of Santa Barbara Alcohol, Drug & Mental Health Services who signed the letter. Apparently the expectations of Medi-Cal are that while my daughter was in the process of breaking, I, a single parent, should have called my primary insurance company to find which facility would be covered as their preferred provider. But this was exactly what I had done but the insurance company had no facilities to offer! The company encouraged me to go out and find something on my own, which is what I did, and to then make double sure that that facility was also a Medi-Cal approved (unfortunately, I did not do this part).
I tried to explain that I had called 86 different facilities in the State of California, and of those, only six were inpatient facilities that would take my daughter with a medical condition and mental illness. Of the six only one would take my primary insurance and that facility was over five hours away. My daughter stayed only one night before she checked herself out because of the horrific conditions there.
This woman just told me that it didn’t fit within the guidelines. She did direct me to the fact that she enclosed a form that I could fill out to appeal the decision.
I have to say that I no longer have any patience with health insurance companies.
The place my daughter stayed at for the majority of the year would not bill insurance – in fact, they wouldn’t even talk with insurance companies and they didn’t produce bills with codes for insurance billing purposes. All their bills stated was whatever month service was for and a cost such as $8,250.00. That was it.
Not only did I have to negotiate between the primary insurance company and the facility, I also had to find a billing format that my insurance would accept and fax the bills to them. The insurance company demanded I use “revenue codes” to identify each item on the bill but wouldn’t help me identify the codes that I should use!
When I sent in my first claim, it came back DENIED! They wanted me to add “procedure codes“, but they couldn’t help me with any of these codes either, so I had to find them myself.
I called behavioral hospitals, medical billers, I even met with a woman that had done behavioral health billing for over 20 years but none of them could help .
I searched the Internet then finally remembered that I had a client whose son had been in an inpatient rehabilitation center. I asked my client if he could let me use one of his bills to build my own bill … thank God they let me and gave me the Explanation of Benefits, EOB for the bill which provided me with every code and format I needed.
My client’s bills also gave me an idea of what would be an acceptable dollar amount under each procedure code. Then I used the schedule from the facility to indicate which days Gabriela had which therapies. My bill had to be listed item by item for each day. This was an amazingly time consuming process and I had to build an Excel spread sheet just to get it done right!
Over four months passed before I received my first substantial payment from the primary insurance company and that was just for 50% of the bill. I had been encouraged by so many people to “pad” the bill so that I would receive full reimbursement but I hadn’t; I felt that the primary insurance would pay because the treatments were covered according to their own rules.
The one thing I didn’t consider was that while I enjoyed a good relationship with my daughter’s case managers within the behavioral health department of the insurance company, the biggest black hole when it comes to insurance is the claims department.
The claims department will deny or piecemeal information to you to drag the process of reimbursement on for as long as possible. I believe the ultimate goal is to make the claimant put so much pain and time into each claim that the insured gives up.
My best advise when dealing with health insurance companies is simple:
- Keep a diary of calls, along with the date, time, who was spoken to, their internal ID number, notes on the topics discussed, and the resolution or date they project for the resolution
- Always follow up, always ask for a supervisor and, if necessary ask for someone who can speak to you in your primary language
- Use the insurance companies web site to send messages to them, letting them know who you have spoken to in the past, what the conversation was, and your expectation of resolution
- Don’t be afraid to contact the department of insurance for your state and file complaints, and let your insurance company know that you will do this and then do it if you don’t get a resolution
- When your claim is paid, file an appeal for any balance they may still owe you
- Make sure you have your insurance plan summary documents to reference in your appeal letter. You will in all likelihood still get denied
- Take that denial and make that the basis of an appeal to your state’s department of managed health as well as the state department of insurance
- At the same time, if you also have a secondary insurance, you may file a claim with them. They should, in most cases, pick up the balance of the claim for you (depending on the plan coverage)
Remember the obligation of the insurance company is to “act in good faith” in exchange for you paying them a premium.
I don’t know what my next step is with Medi-Cal but I do know I’m not done yet.