Health insurance problems

[Arthur Rubin]

I have some serious problems with my health insurance (an ACA plan in California).

I decline to name the insurer until this might be resolved, but....

As far as I can reconstruct the issue, the insurance failed to bill my credit card on December 29 (problem with card expiration), January 12 (insurance billed wrong card), and February 9 (either insurer billed wrong card or the card was reported lost on February 9 (yes, the same day)). As of February 16, they cancelled the policy for nonpayment, even though letters of February 5 and February 9 stated I had until February 29 to pay, and the grace period extended to March 16. I called the insurer and Covered California on February 23, and received inconsistent information. I requested an appeal from the insurer (by phone) on February 24; the (first line) person said that someone would call back, and I gave my cell number. The cell has not received any calls which I cannot account for, answered or unanswered.

To add to the confusion, I now have an insurance subsidy on file with Covered California, but did not have a subsidy at other times during this period. I haven't completed my 2015 taxes, but initial estimates suggest I have to repay the subsidy for 2015 and will have to repay any subsidy in 2016, but I could be wrong.

[LaVidaRoja]

Is there an ombudsman you can reach? Sounds as if you need someone who can go outside of established channels. Either the insurance company themselves or the California exchange MAY have a "consumer advocate" or some such term.

[NYGman]

Not that this answers your question, or helps you in any way, but I hate health insurance companies. I almost lost coverage for a pre-existing condition because of them, and would have ended up bankrupt (of very sick) because of it.

I had left a job, and wasn't starting my new job for a month, taking some time off to travel. A Week Prior to ending my job, I had a physical, saw my specialist, refilled my meds, and got my infusion. [I get an Infusion of Remecade every 8 weeks for Crohn's]. The cost of the infused medicine alone is in excess of 7k, add to that the hospital charge to do it, plus supplies, and whatever markup the hospital does, my bill can be in excess of 10k per visit. As I had just had my checkup, and had seen the doctor, was under medical supervision, and freshly infused, I decided not to take up COBRA for the month I was between jobs. Figuring if I needed to see a doctor, paying them was less than the monthly premium.

When I started my new job, I got new insurance. I went to pre-authorize my infusion, and submitted the paperwork. The insurance denied it, as it was a pre-existing medical condition, because I wasn't consistently under insurance cover. It mattered not that I was under Doctors care, that I had had my checkups, and remained on medication during that period. The only thing that mattered was that I wasn't covered for a month. Needless to say, I went Ballistic. Lucky I was working for a big company at the time, with a great HR department, they helped me appeal the determination, and argued that even though the insurance lapsed for one month, I maintained my health during that period. After submitting a ream of paperwork, letters from my doctors, and probably some medical reports, three months later, they ruled in my favor, although I did have to go out of pocket in excess of 10k, for the next infusion, I got most of it back (Less deductible).

After that, I now HATE insurance companies. However, what I will say is that if you do work for a company who sponsors the plan, have the HR people help you here. However, if this is your own insurance, then I have no answers, but wish you good luck with the evil that is health insurance.

As a post script, I believe my issue is no longer a problem, as I think the affordable health act compels insurance companies to coverage for pre-existing conditions, although I have yet to test that, and don't plan to.

[Arthur Rubin]

I think it's resolved. I'll know early this week.

The fact that they thought I asked for something which I never did may have made it easier for them to "compromise" in accepting full payment for January through April by April 14.

I think I'll send a certified check by registered mail. That way, they cannot claim they didn't receive it....

[Arthur Rubin]

Maybe not. They told me it was resolved, but they didn't tell the front line at payment processing, so there is another appeal in progress. This may just be 2nd line, rather than an appeal, but I'm not sure.

[Gregg]

Lemme tell you some stories about health insurance....I know some people who work fairly high up for a major health insurer, and was at one time very close to someone who works at a prescription fulfillment company I won't mention, but it rhymes with Wellpointe (oops) .....



Some insurance companies automatically "deny" every claim and send a letter to the insured, because that's enough for some of the insured to just figure its not covered and pay it themselves, this works real well on special bills like lab bills and stuff under a certain threshhold, $100, $500.... if you wait a month and just flat ignore it, the system will automatically "fix" it, and pay the claim, but if you paid it they don't do anything, even let you know that if ask they'll reimburse you.

I have this one myself, its what initially caused me to ask my Wellpointe connection and how I started finding out all these terrible things.... I take two prescriptions that are fairly expensive (well, for a person, they're really nothing to Wellpointe) Lyrica and Xralto. I've taken both for years, when I started Lyrica I think it may have still been in studies, but my point is that these two drugs cast something north of a grand a month each. I have a mail order plan and I'm forced to refill through the mail order place, since I do this my main contact is actually online. I always have trouble refilling these two scripts. If they expire every record of me ever taking them ***poof*** from my online history, no record I ever took it, no "call the doctor and ask for a refill" like they do for all my other meds.... and ya know why? The prescription company knows that if it quits coming in the mail, and it no longer shows up online in the "time for a refill" screen, X amount of patients will either figure the Doctor doesn't think they need it anymore and just move on (the company gets out of paying for it forever!) or they at least will go in to the Doctor and maybe, maybe not, get a refill and if they do, maybe the Doctor will switch to a cheaper alternative..(saves them every month forever at least part of the cost!)
With Lyrica this is a pain in the ass and to tell the truth being with out it is just damn uncomfortable, but I'll live. With Xraltol , a heart drug that you shouldn't miss a day at all because just cutting it off can cause blood clots and , well, heart attacks and strokes, its literally a matter of life or death.

I gotta stop, it gets me mad just thinking about it, but working above a certain level at an insurance company seems to me to be pretty close to being in the mob.

[Arthur Rubin]

My pharmacy (3 letters) seems to be up on the insurance company tricks. We've only agreed to pay cash for three drugs;

1. One, because it was a vitamin, and insurance (and the FDA) were challenging whether a prescription was required.
2. One, because my wife was allergic to a binder in the generic, and insurance wouldn't cover the brand name. (She's not presently taking it, but we settled eventually settled for insurance paying what they would have paid if she was taking the generic, and we paid the copayment plus the difference in cost between the brand name and the generic.)
3. One, which they seem to be playing the game described above. I decline to reveal the details of the drug, but we're paying cash; around $360 for a month's supply

The same company, under a different policy, covered a round of an exotic antibiotic, which listed for $2400. We paid the $150 copay under the policy.

[Arthur Rubin]

As far as I can tell, the situation is resolved, and insurance (claims to be) reprocessing claims which they denied because they claimed the policy had expired, and (claims to be) contacting the providers to let them know they are reprocessing the claims. (Except one, which they claim to have denied because the provider hadn't provided adequate information.)

Not all of Blue Shield's computers reflect the reinstatement; we sometimes have to call Blue Shield to have them call the provider to confirm insurance coverage.

The three prescriptions which are not covered by insurance (not the same ones as above; there's a new one which I really think shouldn't be covered, as it's an expensive drug with an off-label use) now total approximately $500 a month.