What is going on with health insurance customer service departments?
November 11, 2016 9:58 AM   Subscribe

With more than one insurance company in the last year, I've had major problems getting seemingly simple billing issues resolved. I'll be told by customer service that I am correct in my complaint and that a problem will be fixed, but then it isn't. I'll call again and state that the problem wasn't fixed after the first call, and the same thing happens. Does anyone have any insight into what's going on here?

This has happened to me with both an individual health insurance plan and with an individual dental plan, with two different companies. The health plan was with Horizon BCBS of New Jersey, and the individual dental plan was with Cigna.

First note that I'm not talking about claims not being paid. I'm talking about premium bills being wrong and policies not being updated properly, during changes like moving to a new state or making some other policy adjustment.

What happens is I'll call the customer service department. I'll talk to a representative who asks me to explain my problem. So I tell them. They look at my account and say something like, "Yes, I see that you are correct. That should be changed. I will send a note to the proper department, and you should see an adjustment in x business days." They ask me if I'm happy with this resolution, and, well, yes, I would be happy if that meant the problem would be fixed, but then I find out a few business days later that nothing was fixed.

In all of these cases, at the end of the phone call I've been asked to answer a brief automated customer service satisfaction survey about how I feel about that particular customer service interaction. And on one hand, the customer service representative certainly gave the impression that they were being helpful. On the other hand, apparently nothing ended up happening as a result of the phone call. Rinse and repeat.

Does anyone actually know what's going on here? Where is the breakdown happening in terms of resolving a problem like this?
posted by wondermouse to Grab Bag (6 answers total) 5 users marked this as a favorite
"Customer service" only exists because in most cases the people paying money (customers) have the power: in a store, for example, they could just not buy the thing or buy it elsewhere. When the people paying aren't the people with power--as with insurance and doctors--everything usually goes to hell. See also: utilities, mortgage lenders, higher education.
posted by Violet Hour at 10:10 AM on November 11, 2016 [5 favorites]

Health insurance is not like other products.

When you buy a car, you choose what you're getting, with limitations for budget, personal knowledge about cars, local options for checkups and repairs, that sort of thing. We can pretty much also choose how we drive: we can get lessons (if we can afford them or know someone), we can pay more attention, be a defensive rather than offensive driver, that sort of thing. As such, insurers have incentives to adjust according to your choice of car, and also your driving record. They have external motivators to offer good service: it's easy enough to find different car insurance. Or even, for people in cities with decent public transportation, go without one entirely. Indeed, we've seen this in Paris, where insurers offer "weekend insurance" rates. Your car's only covered during the week when it's parked, because you're taking public transportation. On weekends, it's also covered when you're driving, because you're getting out of the city. Which they know because they studied their customers and listened to demand.

With healthcare, you never made a choice. You did not choose your body. You do not choose viruses and bacteria. Even elite athletes get cancer, the flu, the common cold.

Private health insurers know this. They know their customers have no choice. There is nothing to motivate them to offer customer service. This is a major reason that most countries around the world have socialized healthcare: it is the government acting as an external motivator. Individuals have zero bargaining power with private health insurance. Governments, on the other hand.
posted by fraula at 10:41 AM on November 11, 2016 [7 favorites]

Spoken promises mean nothing. You need to get a record of your complaint and their determination in writing.

Step zero: Next time you visit a doctor, insist on getting a letter that says "(Your full name) visited on (date and time.) They received (treatment.) This treatment is medically necessary" and have them sign it, and print it out on letterhead. This document is not bulletproof, but the most common thing I run into is insurance questioning whether I actually needed treatment, and this neatly sidesteps that issue. Many doctors also hate your insurance and will do what they can to get the system working so that you get care. If there is someone in the doctor's office who does the billing, ask them what billing code you'll be under, and get a receipt for your visit that day that has that billing code.

You can also try to get pre-authorization for your doctor's office so you don't wind up going somewhere that magically became out-of-network in the time between booking an appointment and seeing the doctor. More documentation is better. Keep everything they mail you in a binder in chronological order.

Step one: insist on getting something in writing, or get the first and last name of the rep and personally record the time, date, name of the rep, and what your issue and promise was. Be clear in what you want and patient with the reps.

Step two: After getting a promise from the rep, insist on escalating every call to the supervisor level regardless of the issue-- confirm with the supervisor that what you asked for it what you're getting, and that you will get that in writing. If you escalate, praise the rep's courtesy and professionalism, but be firm in getting your request made and a record of it mailed to you.

Step three: call back in 24 hours-3 business days and ask about your previous issue's decision. If they have nothing in your record, immediately escalate and ask why, when you spoke to (name) on (date and time) about (issue) was it not recorded? When can you expect a resolution? Return to step two, but subsequently ask for the complaints department and complain about both the supervisor and the rep. Get your complaint in writing. Basically you want to give them one chance, but then go straight to being a pushy asshole who won't go away.

Step four: Depending on what state you are in, you can complain to the state's health care/insurance regulatory board/commissioner of insurance. California's is especially strong. Look up what the process is. If they are billing you improperly, or refusing to cover something medically necessary (see Step Zero) then they can be liable for major fines. Most insurance companies will back down when you get this far.


A transsexual who regularly has to fight with insurance about getting basic treatment
posted by blnkfrnk at 11:03 AM on November 11, 2016 [11 favorites]

Both of those plans are notorious for poor customer service. I work for a health insurance consumer advocacy organization and I deal with with customer reps regularly. Most of my clients will spend many hours of thier life resolving seemingly simple issues as you described. Tips that will help: always get a reference number for your issue. This will cut down on how many times you need to repeat yourself. Ask to speak to a supervisor. You can always escalate an issue to a supervisor, reps don't always follow through or take good notes. File a written grievance, including your memeber id, who you spoke to and when, with a brief description of the issue and the reference number.Your members booklet will have the adress to send it to. File a complaint with the state insurance regulator. Send them the same grievance letter.

New Jersey State Insurance Department
Office of Consumer Protection Services
NJ Department of Banking and Insurance
P.O. Box 329
Trenton, NJ 08625-0329
(609) 292-7272
Consumer Hotline: (800) 446-7467
posted by gnar_gnar at 11:14 AM on November 11, 2016 [3 favorites]

I have recently dealt with this with my health insurance, although related to claims not billing. I also work in insurance.

In my case I contacted them 4-5 times and each time they recognized the problem and stated they would have it fixed. They have no process for following up which leaves the burden on customers and is incredibly annoying when problems are continually not fixed. Customer service is not empowered to actually do anything and they typically have a breadth but not depth of knowledge. Often they can only look up information and pass along information. And once they have passed along a request they are basically done with it.

Insurance companies are often using legacy systems that probably suck. Or they have multiple programs and databases that must be integrated. They might have one for member information, one for plan details, one for claim payment, a separate accounting system, and on and on. They also probably have fairly isolated departments that each handle their one role and don't have much knowledge outside of that role.

The case with my health insurance was related to a provider's network status. Based on what I was told I would guess they manage (or lease) the provider network in a completely different system and it wasn't syncing up with the claim payment system. I am sure customer service was doing their part correctly, but there is no accountability or follow-up with whatever department they were asking to actually fix the problem.
posted by Shanda at 11:45 AM on November 11, 2016

Customer service representatives get paid for shit. The job is usually to get someone off the phone as quickly as possible while also being super nice.

I'm not demeaning customer service. I've done it (for Comcast, uhhhhhhhgghhh)

When I worked for one for the federal student loan servicers, I had an issue with my deferment. I did it online and it said I was ok. I get a bill. I emailed, they said it was fine and I got a bill that was still wrong and my deferment still wasn't applied. This is pretty much the most common thing you can do with a student loan bill....defer.

I called THREE Times over the course of a month to people who were on a different floor of my building... Every single time I'd patiently explain how I had emailed and spoken to someone and what that person's name was etc. Every single time the new person was nice as pie and said the previous person hadn't made the change and they were doing it right now and had made notes and it would take effect in about 3 business days and I could see it online. Every time I was asked if they had resolved my issue and if I was satisfied with the call.

After the 3rd time when it still hadn't happened when they said would (and I would give it a week just to be sure), I finally went to my boss to ask if I could just go talk to someone. She got me touch with a supervisor down there who FINALLY did the thing. No one had ever even made a note on my account. He could tell they had been in there.

And I worked at this place. I also know people who worked the phones there and it's super metric driven. You have to get calls wrapped up ASAP with good survey results. The ability to do a good job is so fraught with roadblocks that many people just do what they can to get good numbers, which is all that matters.

So it's not just you. It's customer service at large places not being about the customer.
posted by sio42 at 7:38 AM on November 12, 2016

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