When a health insurance company is awful, what recourse does one have?
May 16, 2013 12:20 PM Subscribe
What is in place to stop health insurance companies from simply NOT doing things they are contracted to do (i.e.: process and pay for prescriptions. Pay doctors etc.).
Greetings,
My health insurance company (Nippon) is awful. I have been trying to get a medication I am on for 9 months, I have gotten it twice. They just come up with the craziest ways to avoid payment or filling prescriptions. They REGULARLY loose hard copy prescriptions, ask for pre authorizations over and over (ones that are supposed to last a year), make me re submit paperwork for pre existing conditions, just flat out not pay for stuff until I call to complain. I can't believe it is happening, it is so bad. I feel physically ill after talking to them sometimes.
The supervisors are just the same and I just keep jumping and re-jumping through hoops and they just shamelessly break out another one, re run or not.
I used to say "if I didn't know better, I'd think they were trying not to pay for anything". I now know that I DON'T "know better".
I can't drop it as it is associated with employment.
What can one do in this situation?
Greetings,
My health insurance company (Nippon) is awful. I have been trying to get a medication I am on for 9 months, I have gotten it twice. They just come up with the craziest ways to avoid payment or filling prescriptions. They REGULARLY loose hard copy prescriptions, ask for pre authorizations over and over (ones that are supposed to last a year), make me re submit paperwork for pre existing conditions, just flat out not pay for stuff until I call to complain. I can't believe it is happening, it is so bad. I feel physically ill after talking to them sometimes.
The supervisors are just the same and I just keep jumping and re-jumping through hoops and they just shamelessly break out another one, re run or not.
I used to say "if I didn't know better, I'd think they were trying not to pay for anything". I now know that I DON'T "know better".
I can't drop it as it is associated with employment.
What can one do in this situation?
In New Hampshire there's an office of the state Insurance Department that handles medical insurance complaints specifically. They can't help in every case but they respond extremely promptly (possibly because we're a small state and place lots of emphasis on efficient state government, to the point that you can kind of feel rushed dealing with some agencies) and the insurance companies become very responsive once they become involved. Hopefully your state has something similar.
posted by XMLicious at 12:39 PM on May 16, 2013 [1 favorite]
posted by XMLicious at 12:39 PM on May 16, 2013 [1 favorite]
I was going to say refer to the State AG AND the Insurance Commissioner.
Also, find out the name of the president of your health insurance company. Call to get his/her email address.
There is a group of people that typically handles "Presidential Complaints". Write an email, fax a letter directly to the President's office.
To social engineer getting the info do this:
1. Call the HQ organization
2. Tell the person/operator that you want to speak to someone in Pat Smith's office. A live person SHOULD answer the phone.
3. Tell the person, "I am having a huge issue and I'd like to email or Fax Pat Smith the details because I am positive that he/she would be appaled at how I'm being treated."
4. The person should be extremely forthcoming in providing you an email or fax number. This is because your communication will be forwarded to that "presidential complaints" group.
5. If you don't want to hassle, write a letter to Pat Smith at the corporate headquarters address and send it Priority Mail or FedEX, signature required.
Someone who has a flame under his ass should call you to resolve the issue.
posted by Ruthless Bunny at 12:41 PM on May 16, 2013 [3 favorites]
Also, find out the name of the president of your health insurance company. Call to get his/her email address.
There is a group of people that typically handles "Presidential Complaints". Write an email, fax a letter directly to the President's office.
To social engineer getting the info do this:
1. Call the HQ organization
2. Tell the person/operator that you want to speak to someone in Pat Smith's office. A live person SHOULD answer the phone.
3. Tell the person, "I am having a huge issue and I'd like to email or Fax Pat Smith the details because I am positive that he/she would be appaled at how I'm being treated."
4. The person should be extremely forthcoming in providing you an email or fax number. This is because your communication will be forwarded to that "presidential complaints" group.
5. If you don't want to hassle, write a letter to Pat Smith at the corporate headquarters address and send it Priority Mail or FedEX, signature required.
Someone who has a flame under his ass should call you to resolve the issue.
posted by Ruthless Bunny at 12:41 PM on May 16, 2013 [3 favorites]
Vave you talked to your HR Department? They are presumably paying a lot to help insure their employees. If the insurance company is not providing good service, your HR department should get involved and escalate the complaint. If your HR department doesn't care it's time to find a new job.
posted by COD at 12:42 PM on May 16, 2013 [2 favorites]
posted by COD at 12:42 PM on May 16, 2013 [2 favorites]
- You can complain about them in exactly the same way as you would any business; Atty General, Better Business Bureau, local media watchdogs.
-You can (possibly more productively) complain to your employer. Surely your fellow employees are getting the shaft also. Maybe a group of you going to HR and saying this is Not Acceptable will help.
So, insurance companies do indeed work for your company, but if your company is bothering to offer insurance, they must care at least a bit about the service you get. And also, there are always other insurers out there who want your company's business. They have the leverage to go find a better one. What your company culture is like regarding this only you can know. But they will, eventually, drive people away with shitty insurance; it's a benefit like any other and if they are at all worried about losing their employees to the competition, it matters, just like not offering much vacation matters.
posted by emjaybee at 12:43 PM on May 16, 2013 [1 favorite]
-You can (possibly more productively) complain to your employer. Surely your fellow employees are getting the shaft also. Maybe a group of you going to HR and saying this is Not Acceptable will help.
So, insurance companies do indeed work for your company, but if your company is bothering to offer insurance, they must care at least a bit about the service you get. And also, there are always other insurers out there who want your company's business. They have the leverage to go find a better one. What your company culture is like regarding this only you can know. But they will, eventually, drive people away with shitty insurance; it's a benefit like any other and if they are at all worried about losing their employees to the competition, it matters, just like not offering much vacation matters.
posted by emjaybee at 12:43 PM on May 16, 2013 [1 favorite]
What can one do in this situation?
There are other angles to cover, too.
These are some things that I learned both from physicians (not GPs, but experts in their field) and pharmacist. Reflect on the size of the company that is your employer, etc.,and try some of these steps.
• Are you working for a large company? Could you argue that your medication impacts your work (e.g. some meds for multiple sclerosis may keep a patient healthier and able to function in the workplace prior to progressive disease/disability).If you do work for a large, company, talk to HR. Believe it or not, there are large companies that have been able to tell the health insurance company to cover the medication.
• If you work for a small company, consider getting hired by a large company, although it depends if the med truly affects your work.
• Go the company web page for your medication (i.e. pharma company).Some pharma companies offer everything from free medications for a limited amount of time to support. You may also want to consider contacting someone at that company, too.There have been cases of physicians finding out that the insurance company is supposed to cover the medication and they do not. The insurance company is not in compliance and there are cases of the pharma company following up with insurance companies.
• Talk to your physician and advocate communities to find if anyone is having discussion with payers. Yes, there are medications that will help the patient and there have been physicians who 1) write letters to the insurer (and get coverage) or 2) go to meetings to discuss it (this latter one is a policy issue, though, and will only change over time).
• Is your medication also available in a generic form? Some insurance companies will cover generic/not a brand name and your physician may not be aware of this. You may want to talk to your pharmacist because some of them are very aware of these trends and may be able to guide you.
posted by Wolfster at 12:51 PM on May 16, 2013
There are other angles to cover, too.
These are some things that I learned both from physicians (not GPs, but experts in their field) and pharmacist. Reflect on the size of the company that is your employer, etc.,and try some of these steps.
• Are you working for a large company? Could you argue that your medication impacts your work (e.g. some meds for multiple sclerosis may keep a patient healthier and able to function in the workplace prior to progressive disease/disability).If you do work for a large, company, talk to HR. Believe it or not, there are large companies that have been able to tell the health insurance company to cover the medication.
• If you work for a small company, consider getting hired by a large company, although it depends if the med truly affects your work.
• Go the company web page for your medication (i.e. pharma company).Some pharma companies offer everything from free medications for a limited amount of time to support. You may also want to consider contacting someone at that company, too.There have been cases of physicians finding out that the insurance company is supposed to cover the medication and they do not. The insurance company is not in compliance and there are cases of the pharma company following up with insurance companies.
• Talk to your physician and advocate communities to find if anyone is having discussion with payers. Yes, there are medications that will help the patient and there have been physicians who 1) write letters to the insurer (and get coverage) or 2) go to meetings to discuss it (this latter one is a policy issue, though, and will only change over time).
• Is your medication also available in a generic form? Some insurance companies will cover generic/not a brand name and your physician may not be aware of this. You may want to talk to your pharmacist because some of them are very aware of these trends and may be able to guide you.
posted by Wolfster at 12:51 PM on May 16, 2013
Department of Insurance to fix the problem - file a complaint. Also, if there are any advocacy groups in your state working on health care reform, contact them. They are likely looking for stories that reflect how the Affordable Care Act will help people and will help you get your story out. I work for one of those groups in Illinois and if you reached out to me, I would work to hook you up with our state and US legislators, plus media. MeMail me if you can't find any groups in your state and I will let you know who to reach out to.
posted by deliciae at 1:40 PM on May 16, 2013
posted by deliciae at 1:40 PM on May 16, 2013
Seconding talking to your HR department if you haven't already--when the insurance company claimed I wasn't insured with them despite having issued me an insurance card that said I was, HR got on their backs until they figured it out (someone typing in my social security number when the account was created had transposed two digits, turns out). I work for a university with over 1500 employees, however. YMMV if your company is smaller.
posted by telophase at 2:58 PM on May 16, 2013
posted by telophase at 2:58 PM on May 16, 2013
New York State of Health Department of Health Complaints and Appeals
From there, I'd start with what they suggest:
Refer to your member handbook to learn how to use the plan's complaint/grievance process or call the plan's member services or complaint/grievance phone line listed on your health plan identification card. Managed care plans certified by the Department of Health must have a process to receive and respond to complaints and grievances. Many issues can be resolved with a phone call to your plan.
posted by MCMikeNamara at 3:02 PM on May 16, 2013
From there, I'd start with what they suggest:
Refer to your member handbook to learn how to use the plan's complaint/grievance process or call the plan's member services or complaint/grievance phone line listed on your health plan identification card. Managed care plans certified by the Department of Health must have a process to receive and respond to complaints and grievances. Many issues can be resolved with a phone call to your plan.
posted by MCMikeNamara at 3:02 PM on May 16, 2013
I used to work for an insurance company, a good insurance company with an excellent reputation, etc.
On the one hand, insurance is a highly regulated industry and tends to be a nightmare of bureaucracy. It has the somewhat unusual distinction of being regulated by both medical and financial laws, thus the industry is often not so much trying to make you jump through hoops as it is trying to make sure it is jumping through all the right hoops. Very bad things happen to companies found not in compliance with the aforementioned raftload of laws. I have called customers who just could not get me the form I needed in the way I needed it and walked them through how to fill the damn thing out properly. When they were so surprised by my help that they blurted something like "I thought your company was just trying to deny my claim" I let them know the form was not required by the company at all but, was, in fact, required by federal law.
On the other hand, I have heard that most insurance companies train their people to look for a reason to deny rather than a reason to pay. I also know firsthand that, ultimately, insurance works a bit like Las Vegas: They design the game intentionally so there are more losers than winners. It is the only way to keep the doors open and cover the overhead (building, employees, etc). So, no, they really don't want to pay out too many benefits and, yes, they take certain defensive measures to try to reduce the bleeding when someone/something is costing too much. Those defensive measures don't sit well with me at all but many of them are perfectly legal.
In this case, I don't know whether or not to suggest that "bureaucratic nightmare" is the main issue. When that is the issue, persistence in trying to figure out how to dot all i's and cross all t's, etc, can do a lot. When the issue is that they are filing some claims in the circular file (aka trash can) to reduce overhead, the state commissioners, etc, cited above are your best recourse (in the short run -- in the long run, I think we need to do away with employer-based, for-profit health insurance but that doesn't fix your issue in the here and now).
posted by Michele in California at 3:13 PM on May 16, 2013
On the one hand, insurance is a highly regulated industry and tends to be a nightmare of bureaucracy. It has the somewhat unusual distinction of being regulated by both medical and financial laws, thus the industry is often not so much trying to make you jump through hoops as it is trying to make sure it is jumping through all the right hoops. Very bad things happen to companies found not in compliance with the aforementioned raftload of laws. I have called customers who just could not get me the form I needed in the way I needed it and walked them through how to fill the damn thing out properly. When they were so surprised by my help that they blurted something like "I thought your company was just trying to deny my claim" I let them know the form was not required by the company at all but, was, in fact, required by federal law.
On the other hand, I have heard that most insurance companies train their people to look for a reason to deny rather than a reason to pay. I also know firsthand that, ultimately, insurance works a bit like Las Vegas: They design the game intentionally so there are more losers than winners. It is the only way to keep the doors open and cover the overhead (building, employees, etc). So, no, they really don't want to pay out too many benefits and, yes, they take certain defensive measures to try to reduce the bleeding when someone/something is costing too much. Those defensive measures don't sit well with me at all but many of them are perfectly legal.
In this case, I don't know whether or not to suggest that "bureaucratic nightmare" is the main issue. When that is the issue, persistence in trying to figure out how to dot all i's and cross all t's, etc, can do a lot. When the issue is that they are filing some claims in the circular file (aka trash can) to reduce overhead, the state commissioners, etc, cited above are your best recourse (in the short run -- in the long run, I think we need to do away with employer-based, for-profit health insurance but that doesn't fix your issue in the here and now).
posted by Michele in California at 3:13 PM on May 16, 2013
They REGULARLY loose hard copy prescriptions
Are you filling the prescriptions through their pharmacy? If so, are you required to go through their pharmacy and not a local retail one?
I presume that if this is a regular occurrence then you're getting scheduled (restricted) medications, since otherwise you wouldn't be slinging around hardcopy prescriptions terribly often.
If their pharmacy is regularly losing your hardcopies for scheduled prescriptions (especially Schedule II ones), that is a Big Deal, as in DEA jurisdiction big. I don't know offhand who you'd report this to, but at the very least that's a pretty big book you can swing at them.
posted by neckro23 at 4:00 PM on May 16, 2013
Are you filling the prescriptions through their pharmacy? If so, are you required to go through their pharmacy and not a local retail one?
I presume that if this is a regular occurrence then you're getting scheduled (restricted) medications, since otherwise you wouldn't be slinging around hardcopy prescriptions terribly often.
If their pharmacy is regularly losing your hardcopies for scheduled prescriptions (especially Schedule II ones), that is a Big Deal, as in DEA jurisdiction big. I don't know offhand who you'd report this to, but at the very least that's a pretty big book you can swing at them.
posted by neckro23 at 4:00 PM on May 16, 2013
Some resources for you via a friend who is involved in this sort of thing:
Health care reform gives appeal rights, internal and external:
Consumer assistance programs in each state.
State insurance regulators.
Good luck!
posted by sciencegeek at 6:27 PM on May 17, 2013
Health care reform gives appeal rights, internal and external:
Consumer assistance programs in each state.
State insurance regulators.
Good luck!
posted by sciencegeek at 6:27 PM on May 17, 2013
This thread is closed to new comments.
Option A) Change your employer.
Option B) Have your employer change your health insurance.
Option C) Advocate for universal single payer health care.
That's it.
It's important to realize that you are not the health insurance company's customer. Your employer is. The company will not listen to you, they will only listen to your employer. You could sue them, but I can absolutely say the time of the lawsuit would not be worth it to you.
if I didn't know better, I'd think they were trying not to pay for anything
Well, yes, they are trying not to pay for anything. Your health care is a cost to them, which they are trying to avoid.
posted by saeculorum at 12:28 PM on May 16, 2013 [2 favorites]