Once Again, Some Days Becoming a Consumer Advocate Is Tempting

I had several good posts that were calling to me to write about, on this, what promised to be a beautiful snowy January day.

Unfortunately my slack time was eaten up this afternoon, with a health insurance related fire drill. It seems:

• When a certain health plan administrator gets petulant, they go back and disapprove already paid-claims, demanding reimbursement, upsetting the medical professionals and terrorizing us with the prospect of an unexpected pile of rather large medical bills.
   
• It seems that “supporting documentation not supplied” is an apparently valid reason to deny claims (after having been approved, paid, and closed), even though the doctors and hospital involved have already sent complete files…thrice.
   
• Similarly, it seems to be perfectly acceptable for the health insurance customer service folks to insist that all documentation be sent by us as part of our appeal of the retroactive denial…even though the rep admits “the documentation seems to be there, but I can’t pull it up.
   
  I’d argue this point with them further, but I’m inclined to think that it would be best to deny them the “insufficient documentation” rationale when appealing. However,…
   
• Neither the doctors nor the hospital involved mail patient records to patients. A patient must present him or herself in person to request the files, and take physical possession of the files. Never mind that the hospital is 90 minutes away, and the patient is effectively a shut-in at home due to disability.
   
• Now, were this standard property/casualty insurance, this is the sort of fuss that would cause me to go have a chat with the person handling consumer complaints down at the Department of Insurance, whereupon the insurer would get a nastygram from the state, and either the situation would be remedied, or someone with pointy hair would clear the b.s. and explain what really is the problem.
   
  However, because this is employer provided health insurance, it is mostly out of the jurisdiction of state regulation, and is instead governed by ERISA and related Department of Labor regs. A kind person at the DOL EBSA was very sorry to advise me that there is no consumer complaint functionality within their administration; if we have an issue, our recourse is the internal appeals process, followed by a federal suit.

I’d say that this is enough to make me wish for single-payer health insurance…but under a single-payer system, this procedure probably wouldn’t have been available to my wife.

I wonder if Bob Hunter or Birny Birnbaum need any help.