Today’s edition of There Are No Good Health Insurance Companies

July 7: One of my children (“Kid”) has a session with a therapist they’ve seen numerous times. The insurance claim for every previous session has been paid by the insurance company (Blue Shield of California) without incident.

July 14: The therapist contacts Kid and asks if we know why the insurance company rejected the claim.

I log into the Blue Shield website. There is no Explanation of Benefits (EOB) posted for the claim, and there is no explanation in the claim summary visible on the web site for why it was not paid.

I sent a message through the website to member service asking where the EOB is and why the claim was not paid.

July 21: A week later, there has been no response from Blue Shield. I log into the website again to see if an EOB has been posted, and I can’t because the website is malfunctioning in the middle of a weekday. I submit a grievance through the website about the incorrectly processed claim and the insurance company’s failure to respond to my inquiry about it.

July 22: Blue Shield mails Kid a letter saying they’re rejecting the “appeal” I filed because I did not include a form signed by Kid authorizing Blue Shield to speak with me, and we need to start over with the form.

July 28: Kid receives the letter.

I log into the website again, and lo and behold, an EOB is available and I am actually able to download it. It says the claim was rejected because Kid has other insurance to which we have to submit the claim. Readers, I assure you that Kid does not have other insurance; this is simply false.

I had hoped not to have to need to have to speak to human beings on the phone to get this fixed, because we all know how well that usually goes, but at this point I give in and pick up the phone and call Blue Shield.

My company supposedly pays extra for “concierge” service with Blue Shield, which means we have a dedicated team of member service representatives, supposedly more experienced and better trained ones, to handle our calls. But when my responses to the automated phone system’s questions cause it to conclude that I’m calling about a therapy claim, it decides to transfer me against my will outside the concierge team to a “mental health administrator” (MHA), whom (I learned later) is actually an employee of an outside contractor, Magellan, not Blue Shield. Oh, goodie!

I explain the problem to the Magellan MHA, who informs me that she can’t do anything about the problem and I have to call Blue Cross Blue Shield of Massachusetts, since I live in Massachusetts and therefore my claim was processed there rather than by Blue Shield of California. I pointed out to her that the EOB I received came from Blue Shield of California and said I was supposed to call blue Shield of California with any questions. I told her what she was telling me did not sound at all correct. I asked her, “Just to be clear, are you telling me that any time I have a problem with a claim for an in-network provider, I have to call Blue Cross Blue Shield of Massachusetts to get it resolved rather than Blue Shield of California?” She insisted that yes, that was correct.

Spoiler alert: nothing she told me was correct. Nine minutes on the phone, wasted.

I call Blue Cross Blue Shield of Massachusetts, because what else am I supposed to do? It takes 23 minutes on the phone with them for them to confirm that they can’t help me and that I need to speak to Blue Shield of California. They say they’re going to transfer me, but the transfer doesn’t work. However, for the first time in this debacle something goes right: they apparently gave the Blue Shield guy my phone number, and he calls me directly.

I spend the next 18 minutes on the phone with someone from Blue Shield who knows what’s going on and says he’s going to fix it.

So, what happened? Some automated system that Blue Shield participates in that different insurance companies use to notify each other of who their members are inserted incorrect information into Kid’s Blue Shield record falsely claiming they have other coverage. Or who knows, maybe it was done by hand, not by an automated system. Regardless, it’s not only false that Kid has other coverage, but the carrier ID / ID number combination inserted into their record is invalid and the computer knows it’s invalid. But rather than concluding, “Hmm, this number isn’t valid, we should probably just treat it as bad info and ignore it,” their computer decided to just reject Kid’s claim.

How do I get this fixed? The Blue Shield rep I spoke with said he was going to send an email to the department that handles this stuff asking them to remove the incorrect insurance from the record (he can’t do it) and reprocess the claim that was rejected. He said it’ll take about a month. Neither Kid nor I will be notified when it’s done, the claim will just be silently reprocessed. So I have to keep checking the web site periodically to find out when that’s happened. Great system!

I asked the Blue Shield rep how to avoid getting transferred to Magellan if I have to call back and ask for help about this again because this isn’t resolved in a month. He said he didn’t know. I asked, if I just repeatedly tell the automated system I need to speak to an agent, without mentioning that it’s for a therapy claim, will that work? He said it probably would.

I asked if new claims from Kid’s therapist are going to continue to be rejected until this is resolved, and he confirmed that indeed, until the invalid insurance information is removed from Kid’s record claims will continue to be rejected the same way, so if possible the therapist should probably wait a month or so before submitting any additional claims. Brilliant.

In the course of this conversation when I mentioned about halfway through that the claim that was processed incorrectly was a mental health claim, the rep was like, “Oh, I’m not actually supposed to be talking to you about it then. The release Kid filled out online to allow you to access some of their claim information doesn’t apply to mental health claims [If that’s the case, then why can I see them when I log in as myself on the Blue Shield website? 🙄]. If they want you to be able to talk about their mental health claims with us, then they need to go to the web site, scroll down to the bottom, click on Forms, download the Release of Personal Health Information form, fill out sections one through four, skip section five, fill out sections six through eight, sign the form, and mail it to us on paper. Once we receive that form back reps will be able to talk to you about the things Kid authorizes them to discuss with you.”

I pointed out that someone representing Blue Shield had given me completely incorrect information about how to resolve this problem and wasted 23 minutes of my time, and he basically shrugged his shoulders over the phone and said it’s an outside vendor, there’s nothing we can do about it. I responded, “Now hold on, I’m going to stop you right there. Blue Shield is responsible for ensuring that its vendors don’t give wrong information to members, and I am asking you to pass on to your management my feedback that someone at Magellan sent me on a wild goose chase and wasted a lot of my time by telling me I needed to talk to Blue Cross Blue Shield of Massachusetts, and you folks should do whatever is necessary to ensure that doesn’t happen to anybody else.” He said he would pass on my feedback. Will he? who the heck knows. 🤷

In closing, I just want to say, fml.

P.S. Credit where credit is due: the person I spoke with at Blue Cross Blue Shield of Massachusetts and the last person I spoke with at Blue Shield of California were both helpful and put in the time and effort to get me as close as they could to a solution.

Major update August 5: it gets much worse

Kid is scheduled for major elective surgery in three days. It has taken all summer to do all the planning and preparation for this surgery, and it is crucial for it to take place this week because Kid needs to be recovered in time to start their college classes.

The surgeon just called Kid today and informed them that the insurance company is rejecting the pre-authorization for the surgery, because of the problem described in this post which still hasn’t been fixed eight days after they were notified about it, and the surgeon is going to cancel the surgery if the insurance issue isn’t resolved by tomorrow. 😠

I have now enlisted the help of my company’s HR department to put pressure on the insurance company to get this fixed today. We are a small enough company that I was able to reach out directly to a senior HR person and explain to her what is going on. She is as appalled as I am and ready to rumble with the insurance company about it. Having said that, when it comes to health insurance companies and other implacable bureaucracies, willing to fight is no guarantee of success. We’ll just have to wait and see.

→UPDATE→ My HR person’s first attempt to get the insurance company to fix this failed. She called, they claimed Kid’s insurance is in good standing and there’s no record of the surgeon submitting any pre-authorization requests, she called me back and told me that. I explained that there are no pre-authorization requests in the computer because Blue Shield rejected them because of the problem I’m trying to get them to fix. I explained (again) what the problem is. I explained that I knew this was the problem because a Blue Shield employee told me so eight days ago. She is now calling Blue Shield back to have another go at getting them to fix it. *sigh*

→UPDATE→ Blue Shield has now acknowledged the problem (again) to my HR rep and promised her that it will be fixed by the end of today and someone from the insurance company will call the HR rep and confirm one way or the other. If they are telling the truth (big “if”!), then Kid’s surgeon will be able to rerun the insurance tomorrow morning and it will go through successfully. We are crossing all our fingers and toes.

→UPDATE→ Insurance company rep called HR rep, she hasn’t heard back from the department that’s supposed to fix the problem so can’t confirm it’s fixed, Kid needs to call the insurance company, ask to speak to a supervisor, give the reference number of the case, and demand an update on it.

→UPDATE→ Kid calls insurance company, waits on hold for half an hour, “No supervisors are available, one will call you back later tonight when they’re available,” it is now nearly an hour later and nearly 10pm in our timezone (nearly 7pm in the insurance company’s timezone) and still no one has called.

→UPDATE→ The insurance company says they’ve “temporarily” fixed the problem so that the pre-authorization from Kid’s surgeon will go through tomorrow, but they can’t fix it permanently because they don’t know where the bad information is coming from so they can’t stop it from being added back to Kid’s record by whatever is doing it. If that’s the case, then I’m not sure how they can be sure it won’t get added back again overnight and break the claim again tomorrow, but they claim that won’t happen. The permanent fix—figuring out where the bad data is coming from and stopping it at the source—is handled by a different department, the one mentioned above that takes up to 30 days to resolve issues. They gave Kid the company name for the other insurance company they supposedly have (but don’t, actually), and while it’s true that our family has had that insurance in our past, that hasn’t been true since January 2024.

August 6: it gets even worse

Kid’s surgeon’s office has canceled the surgery that was supposed to take place in two days, because the insurance company refused this morning to guarantee in writing that Kid had coverage and said they would not be able to do so for another 72 hours, which was after the scheduled surgery date.

The surgery will probably need to be rescheduled for the middle of the fall semester, and given how long the recovery period is, Kid will probably need to withdraw and miss an entire semester of classes in order to have the surgery.

All this grief and chaos has been caused by a shitty insurance company with shitty computer programs which made shitty errors which they shittily failed to detect themselves and then shittily failed to fix in a timely fashion, which is all part and parcel of the shitty, late-stage-capitalist, collapsing-in-real-time healthcare system in the United States.

But wait, there’s more (maybe even good news)!

So, I am trying not to get my hopes up, but… Thanks to the heroic efforts of my company’s HR rep, the surgery has (maybe) been uncancelled for this Friday.

The HR rep managed to convince Blue Shield to issue a letter confirming in writing that Kid has primary coverage through Blue Shield.

With that letter in hand, Kid went back to the surgeon’s office and asked if they would uncancel the surgery. They said yes on the condition that we sign a waiver agreeing to be responsible for the cost of the surgery of Blue Shield refuses to pay.

We agreed to sign the waiver, despite the fact that there is a non-zero chance that Blue Shield will do its best to find some other way to fuck this up and leave us on the hook, because that’s preferable to making Kid miss a semester of college because of a rescheduled surgery.