Big Blue Monster

Continuing from last time, I had about five claims that were being denied by my shiny new health insurance provider, Blue Shield. I had overcome one barrier (preexisting condition) only to be met by another... Imagine that by now it is approximately April 2010. My new prescription medicine has healed me! However, I am still dealing with the financial fallout...

I was still enrolled in United Healthcare, in addition to being enrolled with Blue Shield. Because UH was provided by my employer (as opposed to being from my spouse), they were considered to be my primary insurance provider. Why is this a problem, you ask?

PROBLEM: Blue Shield slapped a footnote onto EVERY claim, stating that they didn't have to pay a dime because United Healthcare was primarily responsible.

So....back to the customer service minions. I explained the situation to Blue Shield, and even included my explanation of how United Healthcare won't cover it because I don't have a referral to the specialist because they wouldn't give me one. They explained how [they don't give a rat's ass] and that I have to send all the claims to United Healthcare first. I was told that if the claims are denied (and I simply interpreted this as "when" rather than "if"), then United Healthcare could send the claims to Blue Shield to pay any "remainder". This is commonly referred to as "cooperative benefits" when an individual is covered by two health insurance companies. One company processes the claim, denies or pays their share, then sends the leftovers to the other company to pay the remainder.

So....I called up United Healthcare and explained this to them, asking for their cooperative benefits department as I had been instructed to do by Blue Shield in order to set up this cohesion between my two insurance providers. I was quickly informed that United Healthcare did NOT have cooperative benefits (this figures), and that I would instead have to do the following in order to get Blue Shield to pay for my claims:

1) Call up every lab, hospital, and doctor's office and tell them to resend the claims to United Healthcare instead of Blue Shield.
2) Wait for United Healthcare to process and inevitably DENY all of the claims.
3) Take the denied claims, and send them to Blue Shield along with the original claim that was submitted to them in the first place.
4) Hope for the best.

Confused yet? Yes.
Frustrated? Yes.

Anyway, I follow step 1, and wait a month or two for United Healthcare to get around to denying everything. At least I can count on them to do that correctly. They did; step 2 complete!

Fearing what happened with the letter faxing debacle (see previous post), I decided I'd rather take my chances with the postal system. I wrapped up my carefully denied claims and mailed them away to Blue Shield, assuming they would arrive. Luckily, step 4 panned out quite well, and most of the claims were processed and many bills were paid!

In the meantime, I had learned that I could waive out of my employer health insurance (United Healthcare), and I did so promptly. I faxed the necessary paperwork to the Student Health Center, and didn't hear back. A brief call confirmed that they had excluded me from their terrible health plan. Yay!

I thought all was well, until I noticed that the claim to the pathology lab had not been paid. This got a little tricky, and is one battle that as of today, remains a loss for this poor graduate student. Stay tuned...

New Blue Horizon

I had just signed up with Blue Shield of California, and was still very much sick. Excited to be on an actual PPO, I quickly located a specialist that suited my needs and made an appointment. I was excited to meet with a specialist after being told by the ill-informed general practitioner that I did not need one, even though they could not figure out what my problems were or fix them. This was a problem with my United Healthcare graduate student "PPO" since I needed a referral to see a specialist...or even my general practitioner.

Anyway, I waited a month for the new Blue Shield to kick in, and then I went to see my specialist. She was great, and immediately suggested that I have a minor procedure performed in order to investigate my illness. I was scheduled within a week, had the procedure, and scheduled a follow-up appointment. Before going to the next appointment, I had to go to a pathology lab and have more samples taken for analysis. I went to said appointment, viewed results, and received a new prescription medication.

Summary of potential health insurance problems: 2 doctor's visits, one procedure (which involved being put under, a biopsy and brief hospital tenure), and a visit to the pathology lab

About a month and a half into all of this, I was blissfully imagining that Blue Shield was magically taking care of everything. You know....paying the bills, letting me have peace of mind...all that jazz. I was wrong. VERY WRONG.

So apparently, Blue Shield had decided to deny all of my claims on the basis on my having a "pre-existing condition" which exempted them from covering all of my bills. Well, I did, but according to California law, this doesn't matter as long as you were continuously covered under another insurance provider for at least six months prior to switching insurance providers. I had obviously been "covered" continuously by United Healthcare.

Back to customer service....my favorite. I explained that I had been covered, and they said that I had to get a letter from United Healthcare proving that I had been covered by them for at least the past six months, and send it to their provided fax number. I want to note that this is ALL they told me (this will be important later).

United Healthcare customer service.... I explain that I need a letter proving that I was covered for the past six months blah blah blah and the minion seems to understand. I ask her to fax it to me, and she does. When I receive the fax, I discover that she sent a letter expressing that I had been covered for the past 3 months only. >:-O Ok....I call again and explain the situation very carefully. The minion explains that because I am a student and the health insurance is provided on a quarterly basis, that the letter can only reflect a 3 month period. I try explaining that I need 6 months proof, and they are required to grant this to me by law. Minion thinks quickly, and decides that they can send me two letters, one showing coverage of the most recent 3 month period and another reflecting the previous 3 month period. This seemed inefficient, but I went with it.

Both letters in hand, along with my fax cover sheet, I send it all to the fax number that Blue Shield sent me. Thinking all was well, I went on my merry way.

Two weeks later, I notice that none of my claims have been processed by Blue Shield. I call them again, and ask about the verification letter from United Healthcare. They tell me they had never received such a letter. >:-O Ok....I ask how I can get the letter to them as I had already sent it to their fax number and that apparently doesn't work. "Did you put your provider number on the fax?" minion asks pointedly. "No," I say, "Nobody told me to do that. Why would I know to do that?" After further discussion, minion also informs me that I was given the wrong fax number. >:-O Ok, I send the fax again, using my newly garnered information...

I will spare you the details of what transpired, but I will tell you that it took me 4 more phone calls, 5 more faxes to 5 different numbers, people, and departments, and 4 more weeks before they actually acknowledged that I had sent the letter to them. They processed the letter, and eventually re-processed the claims.

Did they pay the bills this time, you ask? NO. While they were no longer denying them under the previously existing condition caveat, they had discovered a new and more annoying way to deny my claims. Stay tuned for more fun times...