Ask the Insurance Warrior
4/29/07

Q: I have been calling my health insurer for months, trying to resolve an issue. If I talk to three different people, I get three different answers about what I should do. They say that they are going to call me back, check with their supervisor, etc. They never call me back. How can I break free from the telephone quicksand of "Customer Care" and make something happen?

A: Of course they don't call you back. They don't want to talk to you ... you are trying to make them pay for something that they don't want to pay for. Why should they change their position because of a phone call? With a phone call, there is no accountability. Nobody knows what you are going through. You have to reinvent the wheel every time you pick up the phone.

The short answer? Stop wasting your breath on the phone, and put it in writing!

Quiz question: What are phone calls to the health insurer good for?

  1. To find out to whom to send your letter (if they will tell you).
  2. To record all of the conflicting answers they give, to include in your letter.
  3. To look for that rare insider who will help you.
  4. To dig, dig, dig for any information that might strengthen your appeal.
I guarantee you, if you engage enough insurance company employees on the phone, you will be able to collect a wealth of slip-ups, untruths, scary mistakes, etc. to add to your letter. If nothing else, you can go on in your letter about exactly what happened all of the times that you called the insurer. Name them, quote them, include the date and time of day when you spoke.

Last Friday, I decided to take a case into my own hands and write the letter myself. Time was of the essence, the patient's husband was worn out. He had been haranging the insurer by phone for months, and they were not budging an inch. We didn't have a whole lot of misdiagnosis, wrong treatment, etc. to report in our letter, so I simply reported what little I knew about what had been happening over the phone:

"I have attempted to resolve these issues with Acme Insurance by phone since the day I received this letter. I have been stonewalled, put off, and lied to by employees of Acme. For example, on 4/18/07, I asked Mary in Customer Care who would be able to negotiate a single-case contract with Dr. Jones' office. I was assured by Mary that my

Case Manager had decision-making authority when it came to contracts. We went to a lot of trouble, and wasted precious time, setting up a call between my Case Manager and Dr. Jones' office. Guess what? The Case Manager has no authority to negotiate contracts.

Was Mary telling a lie, just to delay us until surgery day? Or did she truly not know what duties Case Managers perform? Could she possibly be that ignorant of the process?

This is but one example of the sort of treatment that we have endured. Nobody has a last name, nobody has a phone number. Nobody does what they promise to do. This business with Mary is but one example of the obstructionist tactics which I have encountered, when all I am trying to do is move forward with my lifesaving surgery.

So, because nobody has an answer, nobody has authority, and I have spent the last month waiting for these Acme employees to call me back, I must sit here tonight, six days before massive surgery, and address these issues in writing."

I went on to provide a list of nine cases in the past where Acme Insurance had negotiated single-case contracts, even though they claimed that they never did such a thing.

The patient's husband had been reluctant to send a strong letter to the insurer, for fear that they would somehow turn off the care altogether. I said, "You have to. This is a fight for survival. You can't hold back, you have to hit them with everything you've got, and you have to do it in writing, with cc's to every bigwig, Insurance Commissioner, etc. that you can think of."

Finally, at noon on Friday, he had run out of other options. He faxed my letter to three different people at Acme Insurance. At 10 p.m., he called me, "Within a half-hour, the Medical Director called me on the phone. He had five people in his office. They wanted to know where to call to negotiate with Dr. Jones on the contract."

The name of the game is survival. A half-hearted phone campaign will not spur a bureaucracy to action.

Put it in writing, use the right “power words,” strike the right balance between outrage and professionalism, and they will pay.