Systems breakdown or deliberate rip-off?
This story began over six months ago, according to retiree Bert V. His spouse, Millie, was a veteran of the medical industry and has little confidence in providers or insurers, avoiding them as much as possible. Bert has a lot of medical issues, but Millie was in good health, with some concerns. They left Northwest Allied Physicians to look for a new primary care doctor after she reported as scheduled for an EKG only to find that the orders were for a urine test and there would be no EKG. That, along with support staff attitudes and errors and doctor unresponsiveness, to them and to others they observed, sent them on a search.
Millie asked friends about local doctors, and settled on one who was highly recommended. To date she has not actually seen that doctor, but has been seen by their Nurse Practitioner and sent for various tests. Bert and Millie have excellent insurance, with no co-pays except for prescriptions, as a result of working in union facilities in another state before retiring to Tucson. Several months ago they received a bill, and then a second bill. The total wasn’t all that much, around $40, but that should have been taken care of by their secondary insurance after Medicare paid its share. Then there was a third bill for about $10 from another provider.
Bert’s last employer is in California, is self-insured, and uses an administrative company – we’ll call it Admin — to handle in-state claims. Admin, in turn, contracts with Anthem Blue Cross in California. Claims from Arizona are sent by Anthem Blue Cross to Blue Cross Blue Shield of Arizona. These are all separate companies. Bert wasn’t sure who to talk to and attempted to get the apparent glitch straightened out by email and by phone, but could never get a response or connect with a real person. When he finally did, Admin told him they were having problems with Anthem Blue Cross, and did not have access to claim information outside of the employer’s state.
Millie talked with the provider’s billing department and was told that Anthem Blue Cross had told them the claim had been paid and the check sent directly to Millie and Bert. They never saw any check. When asked about that, Admin said, No, checks go directly to the provider. Meanwhile, the provider’s billing department was demanding payment and, relying on Anthem’s claim of payment to Bert and Millie, implying that they were not being truthful.
After an email query via the Anthem Blue Cross website that went unanswered, Bert received a “How Did We Do?”email survey: he told them in no uncertain terms. That elicited an email response from a manager asking, “What can I do to help?” Bert called several times, with long waits to even talk to an operator; on one call a recorded voice said, “Your wait time is forty-five minutes and one second.”
But even after waiting several times he was told the manager was in a meeting, was out, was unavailable, so he emailed her directly with the necessary information. The manager wrote back that it was not her department but that she would give the information to the right people. They would send copies of the cancelled checks. And then…nothing…for over three weeks. Despite several more pleas for help, they have still not heard a word back, much less anything to show they had been sent checks. And the provider has still not been paid.
Frustrated, Bert looked up Blue Cross Blue Shield of Arizona’s Tucson address on their website and found there were two office locations. He went to the closest one, at 2120 W. Ina Road, but the building was mostly vacant with no sign of BCBS. Millie told some friends about their plight and was told that several had similar experiences. Rather than deal with all the hassle, or the threat of a collection agency ruining their credit rating, they simply paid the usually small, but sometimes large, amounts. One suggested they contact the Arizona Daily Independent; maybe the threat of bad publicity would get some action out of Blue Cross.
Enter your reporter. I called the Tucson BCBS office and did not get the “forty-five minutes and one second” wait time Bert had endured trying to get through by phone to Anthem. Instead the phone rang 25 times and I finally hung up. So on November 26 Bert went to the BCBS Tucson offices at 5285 E. Williams Circle, a 30 mile drive since he lives in rural Pima County, and asked to speak to someone with authority.
A young woman named Erica worked with him for over an hour. She called Anthem Blue Cross, and the providers who were sending the bills. Nothing was resolved, but things were hopefully put in motion, and Bert learned how broken the health insurance system is. As separate companies they do not have access to each other’s records, even for the same claim for the same patient. Anthem Blue Cross farms out the actual work to an unknown company – at least that’s what Anthem’s customer service rep Anthony told Erica and Bert. Millie suspects that company is off-shore.
If the claim is from Arizona, as in Bert and Millie’s case, Anthem passes it on to Blue Cross Blue Shield of Arizona, who cuts the check to the provider – never to the member. If, for some “weird” reason Erica did not know, Anthem sent a check to the member, BCBS-AZ never gets any record of that. One bill of Bert’s, going back to May, was paid on November 15, according to Anthony. The provider says it remains unpaid. Anthony then said he cannot confirm that a check was actually sent.
BCBS-AZ has no access to Anthem’s records, and Anthem, according to Anthony, has no access to whoever is actually processing the claims and said it would take a while to get the information. Anthony suggested that Bert might have thought it was junk mail and thrown a check away without opening it, a variation of “blame the victim.” If Anthem claims to have sent a check to Bert and Millie, BCBS-AZ has no record of it. Nobody knows nuttin’!
On November 30, a week after his visit to Blue Cross Blue Shield of Arizona, and with none of the three delinquent bills yet paid, Bert again called Admin’s Customer Service. After repeating the story yet again, Tiffany told him that she would have to talk to a supervisor and do some research – almost identical words in response to his call to Admin on October 5. They would call back.
Many of Arizona’s residents retired here from other states. If Bert and Millie’s situation is as widespread as it appears to be, it’s not hard to see how those little $10 or $20 or $40 non-payments add up. Even if only a small percentage of subscribers pay it off just to get rid of it and avoid damaging their credit ratings, that little – or in some cases not-so-little — non-payment adds up to hundreds of millions of dollars wrongfully held in the deep “non-profit” pockets of insurance companies like Anthem Blue Cross.
With so many different companies holding a piece of the same action in our free enterprise health system, it appears easy for things to get lost – or is it perhaps that each one is after its own higher profits and some are willing to scam patients, viewing seniors as “cash cows,” to improve their bottom line?
Anthem, the nation’s second-largest insurer, was fined $5 million by California regulators just one year ago for “repeatedly failing to resolve consumer grievances in a timely manner.” The California Department of Managed Health Care criticized Anthem for systemic violations and a long history of flouting the law in regard to consumer complaints. Anthem, based in Indiana, sells Blue Cross policies in 14 states, and had been fined some $6 million previously for similar violations of California regulations.
What, then, can be done, aside from perhaps initiating expensive and time-consuming legal action against giant insurance companies with vast resources? Tune in next week for Part 3: some bad news, some good news, and more on Bert and Millie’s senior saga…maybe!