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Waging War Over Health Coverage


Having a loved one with health problems can be emotionally and physically draining. Fighting your insurance company to pay the medical bills can push you over the edge. I know. I just spent six months battling with my insurance carrier, United HealthCare (UNH), for surgery to help remove a giant mole that covered 80% of my infant son's back. By my count, I logged 200 hours, mostly during the business day, trying to get reimbursed for an $18,000 plastic surgeon's fee. Along the way, many others, including my doctor and several human resource staffers, became ensnared in the mess. In the end there was a simple solution. But it left me wondering why I had to jump through so many hoops to find it.

My experience was fraught with chaos, misinformation, and a level of aggravation that led to insomnia and a constant whooshing sound in my right ear. While I'll be the first to admit that I have drama-queen tendencies, stress is a real byproduct of insurance nightmares: A Henry J. Kaiser Family Foundation study found that 62% of people experiencing problems with health insurance said it caused them stress. That diagnosis is also bad for your employer. "Stress has a huge impact on employee productivity," says Michael Thompson, a principal at consulting firm PricewaterhouseCoopers. Indeed, the Kaiser survey also found that half of the people with insurance problems spent time at work dealing with it.

In my son's case we had problems because a mole as big as Leo's can't just be cut out all at once. New skin has to be grown to replace it. We had to find a plastic surgeon who had experience treating Leo's condition, and there aren't many. We were fortunate to find a leading expert, Dr. Charles Thorne at NYU Medical Center, so close to home. But he was not in my health plan's provider network, which meant I had to pay out of pocket and collect from my insurer.

To begin Leo's treatment last September, Dr. Thorne inserted four tissue expanders in his back. An expander looks like a balloon -- each week a little saline is injected to make it bigger and the skin stretches and grows to accommodate it. But United HealthCare rejected the surgeon's fee, saying the billing code covered the "reasonable and customary cost" for one expander. A customer service rep told me each additional expander had to be inserted in a separate surgery (which means extra hospital stays and anesthesia). Obviously there was a disconnect, and fixing it took a massive amount of time.

What I've learned is that battling your insurance company is like waging a war. You need to attack from all fronts. Here are some tips that can help:

BE AN INFORMED PATIENT

You know that information packet you get when you sign up for insurance? Read it, especially the rules on what procedures and treatments need prior approval. "Many disputes arise because people don't know what type of health plan they have or what services are not covered," says Trudy Lieberman, director of the Center for Consumer Health Choices at Consumers Union.

GET ORGANIZED

Compile a list of every important telephone number, with contacts at the doctor's office, the insurance company, and your human resources department, and keep it by the phone. This will prevent scrambling when you get a moment to tackle calls. "Be sure to record the date and the name of the person you talk to and take notes about your conversation," Lieberman says.

It also helps to maintain a folder with insurance claims, filed by date, near the phone for easy reference, advises Andrew Borislow, whose twin sons have lingering health problems arising from their premature births in 1999. Borislow, who runs a Gwyned Valley (Pa.) company that sells mobility equipment to the disabled, estimates that his sons have racked up more than $3 million in medical bills relating to reconstructive surgery, speech therapy, and cerebral palsy. If you are dealing with multiple procedures, use an expandable file folder. Be sure to bookmark your insurer's Web site, because most claims can be found online. Visit the site to monitor the status of your claims.

CREATE A PAPER TRAIL

Make copies of diagnoses and prescriptions, and keep your records up to date, Borislow says. Get copies of your doctor's notes before you leave the office rather than waiting for the notes to be sent to your insurer. If you write a letter, send copies of all correspondence to your employer's head of human resources, as well as your boss and the person who handles claims at your doctor's office. I mailed appeals to United HealthCare and also provided e-mail updates to my managers and human resources department, which helped me build support at work. Even if you are self-employed, it's helpful to keep a paper trail.

Dr. Matt McAndrew in Washington offers another good tip: Send correspondence by certified mail, and set deadlines for the insurance company to respond. He recently fought his own insurer for 16 months to cover an outpatient procedure.

CRAFTING AN APPEAL

Know what the appeal policy is at your insurer before you get started. "You've got to be able to document what you need," Lieberman says. For example, it helps to provide data from medical journals to show that your treatment is cost-effective.

I botched my first appeal because I didn't have any research to back up my case. In a later one I had lots of documentation, including a referral from Leo's pediatrician explaining why surgery was necessary. I also included photos of Leo's back to show what it looked like before (hideous) and after part of the mole was removed (amazing).

If you need to appeal, pay attention to deadlines. Federal regulations require employer-sponsored health plans to give you at least 180 days to submit an appeal after a claim is denied. For more on appeals, go to the Patient Advocate Foundation (patientadvocate.org) and the Kaiser Family Foundation (kff.org/consumerguide/06-appealing.cfm).

REACH OUT AND TOUCH...ANYONE

It helps to have a point person at the insurer. Borislow suggests asking that a case manager be assigned to your account. A case manager at his insurer, Independence Blue Cross (IBC), helped him get coverage for a feeding specialist since one of his sons has problems swallowing. Borislow's advice? "Make friends with the specialists within your insurer who specifically deal with your issue or disability."

After reading about my insurance battle on the BusinessWeek Working Parents blog (businessweek.com/careers/workingparents/blog/), a reader offered another great tip: Instead of going back and forth between your doctor and the insurance company, schedule a conference call. United HealthCare has a team of nurses who monitor employees of BusinessWeek's parent, The McGraw-Hill Companies (MHP). They proved valuable in getting things accomplished. One of them scheduled several conference calls with the claims department to work through the red tape. Insurers who serve many companies typically have nurses who monitor employees, so get them on your side.

Compare notes with people who have similar medical conditions. Support groups can be a good place to start. For example, a cerebral palsy support group has been a useful place for Borislow to gather advice about filing claims. He even turned up information on getting a hot tub covered for therapeutic reasons.

USE A PATIENT ADVOCATE

If you simply don't have the time or energy to fight, you can retain a private advocate to battle the bureaucracy (BW -- Oct. 24, 2005). Some companies even offer such services as an employee benefit. Health Advocate, a Philadelphia-area advocacy company, has a client roster that includes Home Depot (HD). Health Advocate charges $1.50 to $5 per employee per month. Even better, coverage extends to other family members, including parents. Abbie Leibowitz, chief medical officer at Health Advocate, says even the most complicated claims disputes are often resolved within two weeks with an advocate's help.

DON'T GIVE UP

About half of all health insurance appeals are resolved in favor of the consumer, says Lieberman. In my claims fight it helped that my son's surgeon was willing to extend himself to support our cause. During a peer review with a medical director at United HealthCare, he carefully laid out Leo's case and explained why it didn't make sense to perform multiple procedures to remove the mole on his back. I also spoke to the insurance manager for a top pediatric plastic surgeon in Chicago to find out how her office submits similar claims. She suggested our doctor use a different billing code. Within days of both events, United agreed to cover the surgeon's fee.

United HealthCare spokesman Mark Lindsay says less than 1% of all of United's claims involve errors such as the one I experienced. "When claims are not resolved correctly and the way somebody expects, there should be a mechanism where that can be clarified one way or another. These did not work for you," he says, noting that the company is working to bring its error rate to near perfection. To be fair, I've had good luck with United in the past, and we had no problems with Leo's hospital or anesthesia bills.

Insurance woes are exhausting. I hope they're a challenge you never experience. But if you do, be prepared to fight.

By Lauren Young


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