Have you ever listened to someone and known they were lying to you? Have you felt brushed off, used, abused, and exhausted after every interaction? Have you felt confused and inherently skeptical about the validity of what you were told? Have you thought to yourself, “There has to be a simpler way?” If you answered yes to any of the above, then you’ve handled medical bills, pre authorizations, and health insurance.

This is part three of my episodic retelling of battles fought, questions asked, and lessons learned this calendar year with healthcare and insurance. If you missed them, read part one and two. In this segment I highlight that names are deceiving, very few people are helpful, and it takes a masters degree in communication, religious and maniacal follow up, documentation, veiled threats, and a flexible work schedule to get answers.

I’ve struggled with how to tell this segment because most of the players have “Cleveland Clinic” in the name. For the sake of argument, let’s break this down and outline a legend:

• HOSPITAL: First there is the hospital where I received my care and was inpatient multiple times.
• REHAB: Second, there is the acute rehab facility that has the same name but is in fact a completely different entity but uses the name under a joint venture agreement. Badges and logo use can be deceiving.
• JOB: Third, there is my employer.
• EMPLOYEE HEALTH: Fourth, there is my employee health plan, run by my employer but with their own medical experts.
• INSURANCE: Fifth, there is the insurance company that administers my employee health.

I will endeavor to tell this story in a clear and concise way.

Background

So as a reminder, my doctor said I needed to be in the HOSPITAL in order for EMPLOYEE HEALTH and INSURANCE to admit me to REHAB which my doctors (and me) felt was the best place for me to go.

In the HOSPITAL I was told by multiple people on multiple occasions that INSURANCE was denying my claim for rehab multiple times. Later I learned, it was not INSURANCE, but rather EMPLOYEE HEALTH who thought I did not meet clinical criteria. HOSPITAL wrongly blamed INSURANCE. I learned way too late that EMPLOYEE HEALTH was behind the denial.

When I wrote my appeal letter, I mailed it to INSURANCE. In speaking on the phone with a lovely and helpful individual at INSURANCE, I was told they were not the people who denied my claim, it was EMPLOYEE HEALTH. I was also informed that critical medical information was missing from my file. As someone with a long-documented chronic illness diagnosis, the reason for my hospitalizations was incomplete. Nowhere on my submissions to INSURANCE did it say “multiple sclerosis.” I was assured if HOSPITAL resubmitted this paperwork to INSURANCE, all would be taken care of. I contacted my doctor, provided him links, verbiage, and where and how to submit the missing information including EMPLOYEE HEALTH in the mix.

I received the reversal claim letter following my appeal that I referenced in Part Two. The interesting thing to note was this came from EMPLOYEE HEALTH and not INSURANCE. This comes into play later.

I wrongly assumed with the reversal letter, I would magically receive my $10,000 back in a reasonable amount of time. After more than a month, I contacted REHAB. They were flabbergasted, had no idea anything had been reversed, and were delighted for me. They asked that I send them the reversal letter as they had no documentation of it. I sent them the letter from EMPLOYEE HEALTH. I waited. More than a month went by. I emailed. I left voice mails. I followed up. Finally, after multiple unanswered missives, someone at REHAB got in touch in response to my multiple emails. They rang and said, it wasn’t them, their hands were tied. I needed to reach out to INSURANCE.

I called INSURANCE and was told they had no idea my appeal had been granted and had no documentation of the reversal. They asked me to send the letter from EMPLOYEE HEALTH.

Sensing a theme here?

Complete and Utter Nonsense

As an example to showcase the “NOT IT” culture, please enjoy the date stamp and some of the communication below from REHAB. They acknowledged receipt of all necessary information from me on 6/22/23. Each and every communication below occurred because I reached out, followed up, bothered, pestered, wrote, called, and asked my sister with a law degree for specific legal jargon related to “duress” and “harm”.

• 7/13/23 from REHAB: “I will send an email to our Central Billing Office for an update. I did forward all the information to them the day you sent me the auth letter. As soon as they respond I will send you a response.”
• 9/21/23 from REHAB: “INSURANCE was billed with approved auth. Called insurance and spoke to a person. The claim is being manually reviewed. Insurance requests that we allow 30 days from 9/12/23 for complete review. We need to allow them until 10/12/23.”
• 10/31/23 from REHAB: “INSURANCE is still processing, no payment received to date.”
• 11/29/23 from REHAB: “The payment from INSURANCE has been received and your refund packet was created on 11/14/23. The refund packet needs to get the management approvals, once complete the check will be sent to you.”
• 11/29/23 from REHAB: “Total processing time is 3 to 4 weeks, I have asked for a rush on your packet.”

I emailed, I called, I followed up and I tracked their disregard and at times, incompetence. So either they were lying or incompetent at their jobs; and to be honest, I am not sure which is worse. Insurance, medical billing, and authorizations are a game. It’s a full time job to track, follow up on, and decide if the answers you receive are accurate and truthful. In this year-long saga, the only person who did what they said they would do worked for my INSURANCE company. Yes, you read that correctly — INSURANCE appears to be the proverbial good guy.

I acted as communication liaison and project manager and forwarded information between REHAB, INSURANCE, and EMPLOYEE HEALTH. REHAB submitted the incorrect claim, EMPLOYEE HEALTH never communicated with anyone or shared any paperwork with the systems it allegedly should have, and everyone said there was just one thing missing then I would get my refund.

And still, approaching mid December, I do not yet have a refund. But I shouldn’t worry, I am assured it’s in the works. If only I could be patient.

No one was proactive or helpful. No one, save the lovely woman at INSURANCE, helped me. My assumption is that everyone I followed up with took zero accountability or responsibility to assist. Whether it wasn’t technically their job or they saw forwarding an email as a job well done, I do not know. But their jobs have direct patient impact and real life implications. Perhaps they forgot?

Plus, and this is the kicker, none of this would have been possible if I had not saved the paper copy of the insurance authorization reversal that was snail mailed to my house via the United States Postal Service. REHAB didn’t get it. INSURANCE had to request it from EMPLOYEE HEALTH directly and tried multiple times to connect person to person. INSURANCE continually followed up until they got EMPLOYEE HEALTH on the phone. The letter was nowhere in my electronic files.

I saved the paper document in my medical file but I also took a photo of the letter and saved it to the Google cloud. When on the phone with REHAB and INSURANCE and EMPLOYEE HEALTH and anyone else who requested the damn thing, I sent it directly and waited for acknowledgement of receipt.

One piece of paper could have cost me $10,000. They — and I mean every entity referenced above — are banking on you not following up, not keeping paper documentation, not taking the time to write.

Insurance Math

As if the above paragraphs were not rage inducing on their own, the thing… the one thing… that really really REALLY gets me is that because I put in the work following up, REHAB actually gets more money!

Self pay cost one amount, what showed up in my Explanation of Benefits (EOB) was an amount 5x higher. Once approved, the reimbursement check to rehab totals $14,077.00. So I sent over 20 emails and phone calls over the course of seven months and REHAB gets an extra $4,000.

Why am I sharing this?

Maybe as you read along you’re wondering why I am detailing this healthcare and insurance malarkey. I promise this is not about venting, bitching, and moaning.

I have financial security. I have a flexible job that allows me to make and take phone calls and emails during traditional business hours. My house, food, and healthcare were not impacted by $10,000. But others do not have that luxury.

This insidious and disgraceful healthcare game affects people, real human beings. $10,000 is not pocket change or a copay. Someone with less privilege has to decide if they receive help to walk again or pay rent?

They have to spend precious time and energy fighting when that could be used in healing.

I’m detailing this experience to help others fight, provide a cliff’s notes version or simple best practices. I hope someone gets the attention and reimbursement they deserve.

---