"Are You Sure...?"

As you know, I am in a constant battle with my insurance company. For some odd reason, they do not mind paying for my scans now. Maybe it is because my health care providers fight with them prior to the actual scans, but they sure hate paying for my blood work and pathology reports! Today I received an updated Explanation of Benefits that said they are still denying my blood work from May 6th and June 10th. Soooo, I called them up. They have this game they play with me every time I call to argue about a denied claim. Let's call it "Hide & Seek: Medical Records Edition."

Customer Service Rep: "We would have to have access to your medical records, then medical management has to review it before we can decide it is not a pre-existing condition."

Me: "You have access to all of my medical records beginning in December 2010."

Customer Service Rep: "We do not have any of your medical records on file."

Me: "Yes. You. Do."

Customer Service Rep: "I am not showing any records on file."

Me: "This happens every time I call you people. You tell me you don't have my records on file, I ask to speak to a supervisor, and suddenly--boom--you find those records. So, may I please speak to someone in medical management?"


Customer Service Rep: "Please hold."

Horrible Music Begins Here....


Customer Service Rep: "Ma'am? I spoke to someone in medical management. I don't see anything in your file about melanoma. Are you sure that is the right diagnosis?"

Me: Pause.........consider screaming at her.....decide she probably does not get paid enough to deserve my yelling and say, "Every single claim since January has been for melanoma. I think I know what the correct diagnosis is. May I speak to a supervisor?"

Of course she would not pass me along to the folks in charge, but I did demand her fax number and called up to Memorial Sloan Kettering Cancer Center to have them fax over my medical file again. When I explained to the nurse why I needed my file she said, "They are denying blood work? Blood work is pretty essential to your treatment...That's stupid." My thoughts exactly!

It is almost funny how great I am at arguing with them now. I know their next step. I know that the more angry you become, the more you demand to speak to someone above them, the more they are willing to help you. Why should it have to reach that point? Why should we have to yell and curse and cry before they even consider providing us with information on how to receive answers? I understand it is a business to them. They want to save as much money for as long as they possibly can. But, there reaches a point where it is unacceptable. To deny me for a pre-existing condition and have me send in my medical records is fine. To fight with me for almost 6 months, and claim you don't have access to my records time & time again is unacceptable and unfair to me. I could be using that energy on more important things like, oh I don't know, keeping the cancer AWAY!

Siiiiiiiigh. Let's hope that they will have this problem sorted out soon. I truly do hate when people cannot do their job correctly. Or maybe that is where my thinking is wrong...maybe they are doing exactly what the head honchos want them to do. The more time they deny my claims, the more money they keep in the bank.

It is all such a game...

...& I am tired of playing it.

Full Time Job

Through this whole crazy stay in "Hotel Melanoma" I've experienced issues with my insurance company. Almost every time I go see a doctor, which y'all know is often, I have to call my good friends "And.Them." and explain to them that they have my medical records on file, and yes, I am positive my melanoma is not a pre-existing condition.

Normally--after a nice battle--the problem is solved.

Last week I had to call because I had received an updated Explanation of Benefits stating that And.Them had decided to still deny my anesthesia for the surgery I had in January. Here's the best part: they paid for the operation! I guess And.Them thought I should be awake while being cut in 5 areas. When I called the Customer Service Rep, I laughed after I explained my problem. She said, "I see no problem with getting that corrected." I would hope not...

Today I had to call Memorial Sloan Kettering to see why I owed them $1,727 for my office visit on April 22nd. I knew I had not had anything major done that day, it was just a check-up & signing trial papers! When I called MSK this morning, the patient services rep informed me that And.Them had denied my blood work. My first thought was, Wow! A session with the vampires is $1,727..Geeze! Then I got mad. Denying blood work to a cancer patient seems a bit cruel to me. Blood work is extremely important in monitoring my health...especially now where I am possibly receiving Ipi! The claim simply said that the blood work was a "Non Covered Charge." I thanked the not-very-helpful girl and hung up the phone.

On to my next phone call...When I was initially connected to the very nice customer rep at And.Them she could not find the claim for the service date April 22nd. After some hunting, she found it, and informed me that the provider had already been paid. When I explained that I had just talked to the hospital, she pulled up the details, and said that And.Them had paid MSK $1,600 for service date April 22, 2011. She explained that the claim had been denied at first, but that it had been reprocessed and the provider should have received payment by now. I thanked her for being the friendliest And.Them rep. I have encountered and  I hung up.

Time to call MSK again...I received a much more helpful patient rep. who informed me that they had not received payment from And.Them yet but to give it time. He noted my account, and told me someone would be in touch.

Now we wait...Did And.Them pay? Time will tell.

*I say this after every rant against my insurance company, but I honestly do not know how they get away with the things they do. I got lucky this time. The problem had already (hopefully) been fixed prior to my phone call. But what about all the patients who are too ill to call and fight for themselves? What about the folks who would rather pay thousands of dollars towards medical bills that should have been paid than argue with their company? I just hate that so many people are taken advantage of simply because they can be. I understand that it is intimidating to fight for yourself. Those people get paid to make you feel like an idiot. But we have insuance for a reason! It infuriates me, but what can I do about it? Nothing.

Rant against And.Them is over for today...

Oh, "And.Them."

Me: "So, should I continue with the treatment

you are going to deny?."

"And.Them" Customer Service: "I am sorry."

Me: "How do you people sleep at night?"

And.Them.: "I don't make the decisions, ma'am."

Okay, I let And.Them get the best of me today. I normally stay calm and collected; however, there reaches a point where enough is enough.

My point came today.

I called "And.Them" to check the status on my claims since I am on the Shore with my family instead of in Roanoke. The first person I talked to tried to tell me that she did not have access to any of my medical records. After nearly pulling my hair out with her inability to answer any questions, I questioned how they run a business where no one operates on the same system. Frustrated, I asked to be transferred.

Once transferred, I was required to give all of my information again. This woman claimed she did not have my mailing address on file. "That's pretty ironic since you send me mail."

I ask to be transferred again.

I reach this woman who tells me that my surgery was approved but since I have a pre-existing clause on my policy, the surgery has been denied. I explain to her that I understand I have a pre-existing clause...Someone told me that back in December. Following their guidelines I have had my doctors provide them with my medical information which bluntly states that my cancer was not known prior to January 2011. I explained that I have played by the rules and continue to get the run around...

"Ma'am I do not see how we are giving you the run around."

So, I lost it.

I (loudly) explained to her that I have filed paper appeals, I have had my doctors send in my medical reports, I have pre-authorized procedures that actually are not required to be pre-authorized, and I have dealt with this since December and continue to hear a different answer every time I call.

I know she is limited in what she can tell me, I know she has a greedy boss who would fire her if she showed any sympathy, but my god...I already have cancer. Do I really need the extra stress of being hassled by my insurance company?

After the third time I requested to speak to her supervisor, she transferred me.

I received a voice mail.

Assuming I would never hear from the supervisor, I called the woman who originally approved my surgery.

Voicemail.

About 2 hours later my phone rings...It is the supervisor.

Shocking.

Obvious that she is calling to smooth my feathers, she shows a great deal of sympathy. She reviewed my information, and I quote, "You were diagnosed after your coverage began. This is not a pre-existing condition."

Duh.

She was actually very nice, very sympathetic. I made sure to let her know that the lack of organization does nothing to prove what a "great" company And.Them is. I mean, not even having my mailing address on file? Is that really how they are going to try to get me off the phone?

Nice try.

Don't screw around with a pissed off woman...Haven't people learned that by now?

She is supposed to be calling me back tomorrow. She said some claims are showing as being approved even though I have received letters saying they are denied. Again---lack of organization..........

I honestly do not know why they aren't sued often. Or maybe they are. I now understand why.

Yet Another Argument With Good Ol' "And.Them."

It is no secret that I hate "And.Them."

And it's also no secret that I have

numerous reasons

to hate "And.Them."

So, the lovely insurance company is denying all of my claims except for my PET CT and MRI. Why? They claim my cancer is a pre-existing condition...This is no new information. I knew that my initial office visit with Dr. Cool Guy was being denied prior to my surgery. I thought it had been corrected since Dr. Cool Guy sent my notes to "And.Them" to prove that it was not a pre-existing condition. "And.Them" actually CALLED ME to inform me that my surgery by Dr. Pink was approved; however, when I received my Explanation of Benefits today, it has been denied.

Please tell me how that makes sense.

So, I called the lovely folks at "And.Them." The poor girl tried her hardest to get me off the phone without giving me a direct answer. She actually told me that she did not see my medical records in my file. That would have been all fine and dandy except that I had just gotten off the phone with my "And.Them" RN Case Worker who informed me that there is a big note in my file that lists certain codes which have been determined not to be pre-exising. When the girl insisted she did not have any of my medical records to review, I made her call my case worker. She did. And suddenly, 45 minutes later, her attitude changed.

"I will reprocess these claims. Based on the information in your file, there should not be further problems. You will hear from us in 30 days."

 I wanted a direct answer. I wanted the problem to be fixed today. But, I figure I harassed her for an hour, hopefully she will do her job and correct the problem. (Although I am sure the higher ups of "And.Them" would prefer she ignore me.)

It infuriates me how they treat their customers. Aren't I already experiencing enough stress?

What makes me even more angry is knowing that there are millions of people who don't bother fighting "And.Them." It is intimidating to call them because they make you feel like the lowest of the low. If you have someone who is not experienced in the horror of insurance companies, you can't blame them for not trying to fight. It makes me so, so, so angry. I want to ask them how they sleep at night, but I can only imagine the smart ass answer they would give me...Gotta give them credit. The people who work for them definitely know how to make you feel like crap.

What is the point in having insurance if they are not going to protect you?