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bcbsmfails · 8 years ago

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Six hours of my life I’ll never get back and one unfilled prescription thanks to BCBSM

I used to think BCBSM was a good choice for insurance. My experience with the Indiana branch of BCBS was nothing short of great. When I moved to Michigan, my first employer offered BCBSM and I readily signed up. I didn't need to use it often, but I still paid the high premiums each paycheck in the hopes that it would back me up later. When I took a better job across the state with a second employer, I selected BCBSM over cheaper options based on my experiences in Indiana. I currently pay ~$90/month in premiums while my employer pays ~$490/month on my behalf.

In late November, a licensed and board-certified physician prescribed me a device falling under the durable medical equipment provisions of my BCBSM policy. I called BCBSM in early December and was told that it would only pay for durable medical supplies purchased through an in-network durable medical equipment supplier. The call center agent was helpful and gave me a list of authorized suppliers within a 50-mile radius of my home. The list, for some reason, included Meijer pharmacies which do not handle durable medical devices. I spoke with representatives at all 15 suppliers given to me. Only one had the item in stock and it was tagged as a "cash only" item. The provider stated that because the item was so designated in their system, I could submit a claim for reimbursement to BCBSM as the supplier could not bill BCBSM directly. The provider did state that if I brought in the ICD code from BCBSM, it could try running the code but that I would have to provide payment information in case BCBSM denied the reimbursement claim.

I called BCBSM, again in early December, and spoke with another helpful staffer who confirmed that the device is covered under my policy and gave me two codes to pass along to the medical supply company. I returned to the supply company that then confirmed that its system would not accept the codes. The supplier then offered to call the other suppliers in their network within 150 miles on my behalf looking for any that accepted BCBSM for the device. I waited at the supply company for over an hour while the staffer there called each supply company. None of the suppliers either knew of the device or carried it in stock. The staffer took my prescription information and, as she had stayed half an hour after the business closed, said that she would speak with BCBSM the next day. The staffer didn't have to do any of that extra work but she didn't want me to have to pay $90 out of pocket in case BCBSM wouldn't honor the claim. I waited two days and spoke with the medical supply company staffer again. She conveyed that she had made more calls to suppliers her supervisor had given her and spoke with BCBSM representatives. Again, none of the additional suppliers carried (or knew of) the device. She further stated that BCBSM representatives were unhelpful or "clueless" regarding how to assist with this device. She stated that there were cheaper options on Amazon and, because she could not do anything with it, returned the prescription to me.

In mid-December, I was prepared to spend $90 for the device, out of pocket, and submit a claim to BCBSM under my policy (after verifying with my employer that the device was covered under the durable medical supplies provision of my contract).

Yet, before I did, I wanted to know how much I would receive in reimbursement. $90 out of pocket is a lot. I again called the BCBSM help center and received the following information after 42 minutes and 29 seconds (per my phone's call log) speaking with multiple BCBSM staffers: 1) the percentage of reimbursement changes daily, 2) whether I would receive reimbursement depends on who processes the claim, 3) the call center has no way to contact the billing department, 4) the call center can contact the billing department but wouldn't tell me how to contact the billing department, 5) I had a contract with BCBSM but I couldn't know the terms of the contract, 6) I didn't have a contract with BCBSM and it would be a violation of my employer's privacy to discuss the terms of the contract with me, 7) BCBSM could not tell me the amount of reimbursement I would receive under my contract until I submitted the claim, 8) my claim would likely be denied for unknown reasons, 9) the agent had no idea why my claim would be denied but she felt confident that it would be, and 10) I needed a procedure code despite there being no procedure being performed.

Then she hung up on me without warning and punted me back into the general call queue. After five minutes of waiting, someone from individual policy sales answered. He stated that 1) I should have not been transferred back into the call queue, 2) that he could see I had been transferred from the general customer service line, 3) the number on the back of my card was incorrect and I needed to call the group policy number, and 4) he was confident that someone there would give me the amount of reimbursement I would receive (or at least the percentage of reimbursement).

When I called that number the next day, I spent 52 minutes and 36 seconds (again, per my phone's call log) on the phone with BCBSM where I learned the ten items listed above. After speaking with three representatives, including two who represented that they were supervisors in the BCBSM call center, the final one disconnected the call stating that she would not give me the number to the corporate office and that no one would assist me because it was against BCBSM policy to answer the question I was asking. Before hanging up, despite acknowledging that I was getting a durable medical device, she kept insisting that I needed a procedure code.

Frustrated, I reached out to BCBSM on Twitter. BCBSM responded and asked that I fill out a form so someone could get back to me and assist me. I did and promptly received five calls, between 10 am and 2pm, while I was at work in my 8-5, full time, job. The caller left a message with her first name only on the last call and, without leaving a call back number, stated that she would try me the next day. The next day, I received three calls between 9am and 3pm with similar messages left and without any contact number. On the third day, I received another call with another message. At lunch, I called the number appearing on my missed call list and asked to speak with the woman (who only left her first name) who had been calling me. The agent stated that without knowing her last name, I couldn't be helped because BCBSM is a large company and she could be in any department. Given that I only knew her first name and not the department in which she worked, I was out of luck.

That evening, January 13, I received an e-mail stating, in relevant part, "To make a determination on whether your DME item is covered or how much would be allowed I would need additional information. I would need a procedure code, diagnosis code, name of provider and their telephone number." I responded within hours stating that there was no procedure or diagnosis code available as I intended to purchase the medical device out of pocket and seek reimbursement. I specifically asked "I want to know the amount I will be reimbursed under my policy because, I am not willing to pay $90 out of pocket if BCBSM will not reimburse me" and that I "only want to know the approximate amount I would receive back or the percentage of reimbursement available" as I can do the basic calculations. In response, the worker who had called me for three days without leaving any contact info, stated that she had contacted the medical provider and "they advised that this is a cash only item and not billable to insurance." She further stated that "Based on the information I have received from the provider and what information you have provided" the item "is not a payable item under your contract." In response, I asked whether BCBSM was "refusing to reimburse me for a device for which I have a valid prescription and has been deemed medically necessary."

Five days later, on January 18, I asked the worker to respond to my inquiry. In response, she stated "Please resend your earlier message. This is the only response we have received." In response, I sent her a screenshot of the last message sent on at 4:49 pm on January 13. On January 19, the worker again responded that the determination of the device not being covered was based on information received from the medical supply company, the information I provided, and my contract benefits. (The contract benefits which specifically provide for coverage for durable medical equipment.) In response, I asked whether another supply company would provide coverage and noted that she had not answered my original question regarding refusing to reimburse a device that was deemed medically necessary. The next day, the worker responded that regardless of the provider the device is not part of my policy. On January 20, I asked for the specific contract language showing that the device is not covered.

On January 23, I received that while she was happy to send me "your benefit plan guide," BCBSM "internal documents cannot be forwarded to you with that level of detail." After repeatedly advising me, over the course of a week, that BCBSM would not cover the device, she wrote "If you choose to purchase the item, you may submit for reimbursement. If it is denied, you will be provided appeal information on your denied claim." In response, I noted that she "provided inconsistent information again. You just suggested that I purchase the item and seek reimbursement while you earlier indicated that any such claim will be denied. Your answers make no sense and, at the end of the day, I'm likely out $90 for a device that my employer has said is covered under the terms of my policy."

At 5:15 pm on January 23, I received a call from the same BCBSM number used in the previous attempts to call me. I answered and the worker began telling me the same ten things I'd previously discovered. (The call lasted 20 minutes and 19 seconds per my phone log.) At one point, she invited me to tell my story. So I did. She interrupted me repeatedly to say that I other workers had misled me and that, if I really had been provided any codes--which, again, I had been provided two codes--it was a mistake. When I asked her to examine my file and the notes from my previous calls, she dismissively said that she didn’t have access to those and that she could only go by the information in my e-mails. (This, of course, being contrary to the reality that she could see both my account and policy.) She then went on to say she was doing me a favor by staying "after her shift" because she understood that I was not reachable during normal working hours.

She said that she could not tell me what information had been received from the medical supply company, acknowledged that whether my claim would be denied, or approved (and the specific amount or percentage of reimbursement) would depend upon the person working and how they handled the claim. She stated that she had contacted the medical supply company, “which was unusual” and that she had looked up billing codes which “was also unusual” in an attempt to assist me. Further, she reiterated that the amount of coverage changes every day. She stated that the item was not covered under my policy but would not provide any documentation or contract language supporting that assertion. She then castigated me for not previously asking for a list of covered durable medical devices.

When I said that I had called all the suppliers within a 150-mile radius of my home, the worker laughed and sarcastically said "really?" I responded with what I wrote earlier, that I had called all the ones given to me by BCBSM representatives and stood at the medical supply company while they contacted the other providers in their network extending approximately 150-miles around the area.

After another round of assuring me that my benefits did not change daily, only the amount of reimbursement BCBSM would cover, the worker invited me to "follow the orders of my doctor" and, if I so chose, to purchase the item. She stated that, again, if I so chose to purchase the item, I could submit the claim and, if denied, BCBSM would provide me appeal information. It took ten minutes for her to admit that my claim would likely be denied and that I should just hope for success on appeal. She could not provide any information about the appeal process. At the end of the call, she stated that she was instructing the person emailing me not to respond as she had resolved my issue via phone. She again stated that she had stayed after her shift and was trying to help me. Yet, her suggestion was to purchase an item (again, if I so chose as she was not advising me to do anything) that was deemed medically necessary and backed by a prescription, submit a claim, get denied, and hope for the best on appeal.

So, in the end, BCBSM suggests (without suggesting that I do anything because BCBSM makes no recommendations or suggestions) that I spend $90 out of pocket and, effectively, hope that the BCBSM appeals process comes out in my favor. As I pay $90 each month, and my employer pays $490 each month, I should be provided with specific information regarding my benefits. Having a BCBSM employee offer to happily send me "general benefit information" is insulting when I'm trying to budget for a purchase and BCBSM has the information I need to make an informed decision. Reaching out for help from my insurance company, in a time of need and in reliance upon it, should not be met with sarcastic responses asking whether I had 1) really received two billing codes and 2) really called all the medical supply companies you gave me. (Hey, BCBSM, you’re welcome to my phone records and I imagine that the medical supply company will also verify its efforts.)

For the amount of money that BCBSM receives each month from me, disregarding the obscene amounts of money it receives from my employer on top of the hundreds of employees with BCBSM contracts at my workplace, I don't understand why getting a $90 device reimbursed has produced so much headache and stress. In the end, I guess I won't follow the prescription written by my doctor. (But not because BCBSM advised me to do so. BCBSM wants me to "follow the instructions of my doctor" without giving me information to make an informed decision regarding my budget.) Thanks, BCBSM!

#BlueCrossCares. Right.

#blue cross blue shield

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