HELP with Anthem Insurance Company

[more2adore]

Yes, I've read your posts about your brothers and really empathised! They're lucky to have you, and we're lucky on this forum to get to benefit from your advice as well.

 

[southernlady]

@more2adore I can sympathize.
Back in 2000 we moved from Missouri to Michigan. Change of job type move. Okay, about 2 years later I start getting bills from the University Of Missouri hospital system telling me I still owed money. Since we had paid the copay as we went along AND checked the EOB's as they came in (they still did snail mail back then), I KNEW they were just trying to ding me out of money as most people see something like that and just pay it. You know the difference between what is charged and what the insurance company pays? Total was about $1800 and for us, that may as well been 10 grand.

Okay, so I don't get mad, I get EVEN. First, I found all but ONE EOB...and made copies. ALL the EOB's I found said MY part was either zero or a figure I matched to a check we used to pay it and I made copies of those as well (the one missing cost me $12.00 in the end because I couldn't find it).

Then I start the phone calls. Now unlike you, I was only one time zone off. Since I had the EOB's I didn't bother the insurance company. They had done their part. But I called the Financial people at the hospital. And then we start the going around in circles. After about a month, I did some digging. (they had also, by then, sent notice that it would be sent to a collection agency). Now this was 2002 and not everything was online but what WAS online was the employee roster at Univ of Missouri Hospital. So I went hunting for the head honcho...ended up calling (and getting him to answer his own phone) the Chief Financial Officer and explained what was going on. I was polite but firm. HE called down to the supervisor of that section and told her to FIX IT.

In the end, I did have to pay the $12 for the EOB that was missing in action but the rest...they ate! But I always wondered how many others just paid what they were told they "owed" cause they didn't keep records like we did and weren't willing to fight the system.

 

[Spiky Bugger]

State of Virginia. In-laws are in AZ.

Actually, I guess technically it's my employer's money. Since I left in the middle of the FSA year, I had only paid about half of the amount of my FSA, and I used 100% of it up. I double-checked with my employer that I was allowed to do that - apparently they pay the remainder, and it's a risk they take with offering FSAs since they know employees can leave at any time, and they consider it a cost of doing business. But yeah, I get what you mean. Aetna is being ridiculous. I don't have the EOB for this because it arrived at my house after I'd moved and my mom can't find it, and I can no longer access Aetna's online system, either. But I can probably get a copy from Aetna if it will help with the FSA. They're not nearly as hard to deal with as Anthem.

Luckily I can make phone calls via Skype, so I can call for free. I'll just have to keep getting up at crazy times until this is handled.

Once I figured out that "you can spend 100% of your FSA at the beginning of the plan year and if you leave before the end of the year, oh well"...you don't think I let THAT little benefit go un-utilized, do you?

Yeah...ugly letters...threatening, ugly letters.

 

[DianaCox]

I already have a call in to the VA Corporation Commission - this is the guy I've been dealing with on a case involving my dental insurance refusing to pay for my crowns - not sure he's the right person, but he would know who is:

[Deleted to replace with updated contact info]​

I'm pretty sure insurance companies don't like getting calls from his office.

ETA: Nevermind - I just spoke to him (Ombudsman at VA Corporation Commission) and this is where you need to file your complaint:
To file a complaint with the Virginia Bureau of Insurance, you can access information and the online complaint portal here: http://www.scc.virginia.gov/boi/complaint.aspx

 

[southernlady]

Question? Is Athem asking for just what you spent from the FSA? Or the entire amount that was billed before it hit your FSA?

Okay, example, a prescription you get. The insurance has a discounted price they pay and they charge you a specific copay based on your policy. You can use the FSA to pay that copay. So is it the copay or the entire amount since they CLAIM it isn't Medically Necessary?

 

[more2adore]

I have GREAT news. Last night (well, 1 am our time here... about 11 am EST) I called Anthem, armed with all the info I'd gotten here, and I didn't have to use all of it. I explained my situation, and that I had an EOB in front of me (Aetna was a big help when I called them before Anthem). The person I spoke to pulled up my account, said "Wait... what? That isn't right. Give me a sec." I hear furious typing for three minutes, and then all of a sudden, "Okay, I'm REALLY sorry about that. I've fixed it. This is definitely a medically necessary expense and we're approving all but $1.81 of it. I'm really sorry for all you've been through trying to get this worked out with us." $1.81 is the cost of regular stockings you can pick up at Walmart. They're covering the difference. I think THAT's weird, but whatever. I asked if they could waive it, and it's a no-go. It is WELL worth $1.81 to be done with all this! So now I send them a check for $1.81. So happy this is resolved - Diana, you are the BEST.

 

[southernlady]

YEAH!!!!

 

[more2adore]

It was the copay they were claiming was not medically necessary, southernlady. lol. Which makes no sense.

 

[DianaCox]

Well I'm glad, if only because it makes me 1 for 4 today in the insurance wars.

 

[Spiky Bugger]

Well I'm glad, if only because it makes me 1 for 4 today in the insurance wars.

Ut-oh...were the other three personal or pro bono. Not that you like losing ANY of them...but...some cost you money and the other just hurt your feelings.

 

[more2adore]

What SB said! Sorry you're not 4 for 4 today.

 

[DianaCox]

My DeltaDental appeal (they refused to pay for any of my last six crowns, saying "Replacing tooth structure lost by abrasion, erosion, attrition or abfraction is excluded under this plan" - so WTF IS covered then???) - finally was told I lost the second level appeal, and that I have no further appeal rights like external review, because of the type of plan I have - so filed a complaint with the VA Corporations Commission for their procedural as well as substantive wrongful behavior.

My brother's Exemption from the HMO version of LA County Medi-Cal has STILL not been processed, allegedly because the MALS surgeon's office did not submit progress notes (I'm sure she did) back on Aug. 19th - but now, since he has been found to not have MALS, I don't know if they will do that; also, the MALS surgeon referred him to a GI doc at UCI, and an appointment was made, but then UCI canceled it, saying he could get an LA County GI doc. I spent a good part of yesterday trying to find one at UCLA/Reagan, but did not get an answer back from the GI doc I picked based on publications (I ferreted out his email addy, and sent him an email, but he has not answered) - BUT - my brother needs a referral from UCI, AND he needs to have the Exemption from the HMO and to have been given the right to stay on straight Medi-Cal - but that has not been done yet, so he's in limbo.

Someone else in my family needed a specialty referral for a psych issue that came up, and I had gotten their BCBS insurance to tell me what programs were available - I found a residential program out of state affiliated with one program that BCBS had given as being in-network, and (although frankly, it is no longer of interest right now) the residential program had been trying to get verification of benefits since Wednesday - the verification office closed early on Wednesday, nobody answered on Thursday, on Friday they closed at 10:30 AM (!!!), on Monday, the program apparently called MULTIPLE times, was put on hold for 30-45' and then abruptly the call was dropped. The residential program called me this morning to apologize and explain what happened, and I called BCBS and went thermonuclear on their collective *****. Later today, the residential program called me back, and said that they finally got a call back with the requested information - the patient does not have residential treatment benefits available - not that that was desired (in the meantime, a suitable outpatient program was found), but SHEESH!! What if it really HAD been a serious emergency? I'm still furious about that.

In addition:

Unbelievably, there are at the same time TWO potential DS patients Larra and I have been working with, who have self-funded plans with restrictions on where they can get bariatric surgery, and we are trying to get their employers to waive the restrictions, since there are no suitable in-network surgeons or facilities. We're waiting to hear about one, which at least had an appeals process, but the other one's employer is being a complete ******, both HR and legal, and the patient is now having to work with a lawyer - I HATE when that happens.

And my daughter's ******* insurance company - which is merely the administrator of HER self-funded plan - used an unfairly expansive interpretation of "infertility treatment" and the assertion that there is only one possible way to code oocyte cryopreservation, to refuse to consider that her situation is for preservation of fertility, which is NOT the same thing (her ovaries are being destroyed by endometriosis). It's kind of like the distinction between getting breast implants for cosmetic reasons, rather than post-mastectomy - it is the same procedure, but for different reasons. I am trying to decide what to do next, as I negotiated a self-pay rate with the clinic that is less than $5K/cycle (she will need 2-3 cycles as the first one only ended up with 6 frozen oocytes and they want her to have at least 20), which makes filing a Federal ERISA suit financially untenable, but I am angry for other women who are being denied as well. Trying to get a class action attorney interested.

Oh, and I billed a half hour of actual work today too.

 

[more2adore]

Seriously - I don't know HOW you do what you do day in and day out! You're amazing. I would go criminally insane.

 

[DianaCox]

Yes, that's what a lot of people would say. I call it "building my alibi" (pleading insanity) for when I REALLY run into someone who needs killin'.

When I see how hard it is for ME, with 10 years of pro bono experience doing this, to get insurance companies to behave ethically, I just cannot keep my mouth shut and my fingers still, because how the **** is someone without my advantages supposed to be able to do it???

 

[Spiky Bugger]

My DeltaDental appeal (they refused to pay for any of my last six crowns, saying "Replacing tooth structure lost by abrasion, erosion, attrition or abfraction is excluded under this plan" - so WTF IS covered then???) - finally was told I lost the second level appeal, and that I have no further appeal rights like external review, because of the type of plan I have - so filed a complaint with the VA Corporations Commission for their procedural as well as substantive wrongful behavior.

My brother's Exemption from the HMO version of LA County Medi-Cal has STILL not been processed, allegedly because the MALS surgeon's office did not submit progress notes (I'm sure she did) back on Aug. 19th - but now, since he has been found to not have MALS, I don't know if they will do that; also, the MALS surgeon referred him to a GI doc at UCI, and an appointment was made, but then UCI canceled it, saying he could get an LA County GI doc. I spent a good part of yesterday trying to find one at UCLA/Reagan, but did not get an answer back from the GI doc I picked based on publications (I ferreted out his email addy, and sent him an email, but he has not answered) - BUT - my brother needs a referral from UCI, AND he needs to have the Exemption from the HMO and to have been given the right to stay on straight Medi-Cal - but that has not been done yet, so he's in limbo.

Someone else in my family needed a specialty referral for a psych issue that came up, and I had gotten their BCBS insurance to tell me what programs were available - I found a residential program out of state affiliated with one program that BCBS had given as being in-network, and (although frankly, it is no longer of interest right now) the residential program had been trying to get verification of benefits since Wednesday - the verification office closed early on Wednesday, nobody answered on Thursday, on Friday they closed at 10:30 AM (!!!), on Monday, the program apparently called MULTIPLE times, was put on hold for 30-45' and then abruptly the call was dropped. The residential program called me this morning to apologize and explain what happened, and I called BCBS and went thermonuclear on their collective *****. Later today, the residential program called me back, and said that they finally got a call back with the requested information - the patient does not have residential treatment benefits available - not that that was desired (in the meantime, a suitable outpatient program was found), but SHEESH!! What if it really HAD been a serious emergency? I'm still furious about that.

In addition:

Unbelievably, there are at the same time TWO potential DS patients Larra and I have been working with, who have self-funded plans with restrictions on where they can get bariatric surgery, and we are trying to get their employers to waive the restrictions, since there are no suitable in-network surgeons or facilities. We're waiting to hear about one, which at least had an appeals process, but the other one's employer is being a complete ******, both HR and legal, and the patient is now having to work with a lawyer - I HATE when that happens.

And my daughter's ******* insurance company - which is merely the administrator of HER self-funded plan - used an unfairly expansive interpretation of "infertility treatment" and the assertion that there is only one possible way to code oocyte cryopreservation, to refuse to consider that her situation is for preservation of fertility, which is NOT the same thing (her ovaries are being destroyed by endometriosis). It's kind of like the distinction between getting breast implants for cosmetic reasons, rather than post-mastectomy - it is the same procedure, but for different reasons. I am trying to decide what to do next, as I negotiated a self-pay rate with the clinic that is less than $5K/cycle (she will need 2-3 cycles as the first one only ended up with 6 frozen oocytes and they want her to have at least 20), which makes filing a Federal ERISA suit financially untenable, but I am angry for other women who are being denied as well. Trying to get a class action attorney interested.

Oh, and I billed a half hour of actual work today too.

Well...crap.

All I had was a credit card number pilfered. Kid stuff.

I do not want to trade days.