On April 24, I wrote my Insurance companies are evil post discussing my frustration over getting Gray’s therapy paid. For the last month, I have been living through Part 2 of that story.
When last we left off, Gray’s behavioral therapy hours had been cut back from 20 per week to 15. That was a loss, but it only lasted for a short while because we were able to get more hours approved for the summer when he was out of school. Concurrently, I was told that our insurance carrier was not going to continue their individual contract with my therapist. As I detailed in my post on April 24, I won that battle. We were given a 6-month extension of our therapist’s contract and she was encouraged to apply for in-network status.
As our glorious summer came to a close, I started thinking about the renewal of Gray’s treatment plan that was do mid-September. Our therapist began the process of applying for in-network status with our insurance company at the end of July. Unfortunately, we quickly found out that was not enough time to complete the process. We were told that the process generally took many months. I was stressed, after spending the required $10K out-of-pocket on in-network providers, all of Gray’s therapies have been getting paid at 100%. On the other hand, our out-of-network benefits require us to spend an additional $20K out-of-pocket before the insurance will pay for any portion of our bills. At a rate of approximately $1,500 per month, you can understand why it is important to me to keep our therapists in-network.
Gray’s therapist furiously submitted the required information and begged anyone she could to fast-track her application. Fortunately, it has been going much quicker than anyone expected, just not quick enough. As the September re-authorization date came and went, his therapist’s in-network status remains in process. I spoke with our autism care advocate at the insurance company and the conversation quickly headed down the same road as the one that we had in April. I asked for a short extension of our therapist’s contract, she said it would not be possible, I asked to speak with her supervisor, she said she would pass on the message…same story different month. After speaking with her (yet unnamed) supervisor, she told me that my only option was to file a letter of appeal with the appeals department. I asked her if she thought that would be productive and she said she had no idea.
Then, things got a little weird. I already had the name and phone number for her supervisor because I had found it back in April through my amazing sleuth-skills. Rule number 1 for parents in my situation: always keep a record of who you have spoken with, their position and their direct extension. So, I left a message for our advocate’s supervisor giving a brief explanation of our situation. I told her that I knew she wanted us to file an appeal, but I would really appreciate the opportunity to speak with her personally. I got no response. I left another message the next day. Then, I got a call from our advocate who said that her supervisor had received my message and told her to call me and say that my only option was to file a letter of appeal. I asked her if she would ask the supervisor to call me. After a couple of days, I called the supervisor and left another message. This dance went on for about 2 weeks. I would leave 2 or 3 messages for the supervisor and then her subordinate would call me to say that my only option was to file an appeal. It was maddening. When I asked our advocate why her supervisor would not call me herself, she said she did not know. When I asked her if she thought that was strange, she just said that I was making her uncomfortable. Fair enough. I hung up the phone with her and called the main number to start hunting down the supervisor’s supervisor (the grand-supervisor, if you will).
One hour and 3 call-transfers later, I was on the line with an unspecified person who claimed to be able to access the supervisors, but would not grant me access. She said, “I guess I don’t understand why you don’t just do as you’re told and file an appeal.” Well, my first thought was, “It’s not for you to understand. You have no authority to affect this situation either way, so I don’t really care what your thoughts are on the matter.” Of course, I did not say that. What I said was, “as the mother of a child with severe autism, I don’t have a lot of spare time to draft letters with my therapists and send them off to some unknown place where they may or may not be read or answered. I would rather speak with someone who knows this case so we can have a productive conversation.” Her response was astounding.
“Ma’am, you can CALL and CALL and CALL and CALL and CALL, but the answer is still going to be the same. File and appeal and stop trying to talk to supervisors.” Once again, I was brought back to the film that I referenced in my Insurance companies are evil post from April. During the trial, the mother of an ill child reads a letter from her insurance company in response to her repeated phone calls. The letter says, “you must be stupid, stupid, stupid.” I’m pretty sure that was the same thing that this insurance representative was saying to me. She thought I was being stupid, stupid, stupid. She was wrong. I calmly asked to be put into the voicemail of the grand-supervisor. She complied. That gave me the name of this mysterious wizard behind the curtain and I was able to use my super-sleuth skills to figure out her email address. Here is the email that I sent to her:
Good morning Dr. Hxxxxs,
I left a message for you yesterday after spending a very frustrating 40 minutes on the phone with a UBH representative who did not want to allow me to contact you. Here are the issues that I would like to discuss with you:
1. My 7-year-old son, Gray, is severely autistic. He is non-verbal, not fully toilet trained and has many behavioral challenges. I have been very fortunate to find an excellent BCBA who contracts with truly gifted therapists. Together, they have made some wonderful gains with my son over the last year. Until last March, my son’s BCBA has worked with Gray under an individually negotiated contract with UBH. Last March, when his approval was up for renewal, we were surprised to find that UBH would not continue their contract with Lxxxx. Fortunately, after much discussion, UBH agreed to extend her contract for another 6 months so that Lxxxx would be able to apply for in-network status.
2. Lxxxx began the application process at the end of July. Both of us thought that would be enough time to gain her status before his current authorization expired on September 18th. We were incorrect. Although she is VERY far along in the process and her audit is almost complete, she has not yet received her in-network status.
3. I spoke with Dr. Nxxxx, our autism care coordinator, to ask if we could have a short extension of Lxxxx’s contract to bridge the gap until her application is approved. Dr. Nxxxx told me that was not possible. I asked if I could speak with her supervisor about this and she told me that she would issue a request on my behalf. The next day, Dr. Nxxxx called me back to tell me that her supervisor, Dr. Hxxxx, said that my only option was to write a letter along with our BCBA and send it to the appeals office. I asked Dr. Nxxxx if she believed that this would be an effective option in getting our claims paid at in-network rates. She said that she did not know because she had never seen an appeal for this kind of issue before. This option is not very appealing to me because I am very skeptical that it will be effective at all. As a mother of 3 children with one being severely autistic, I do not have time to compose and file paperwork unless I am certain that is will be a worth while endeavor.
4. Because Dr. Nxxxx told me that she was not authorized to do anything other than offer me the appeals information, I decided to contact her supervisor, Dr. Hxxx. I know from our experience back in March that Dr. Hxxxx, unlike Dr. Nxxxx, has the authority to extend Lxxxx’s contract. I have left several messages for Dr. Hxxxx on her voicemail asking her to contact me in hopes that we could discuss our situation. Dr. Hxxxx has never returned any of my calls or directly contacted me in any way. Instead, she has asked Dr. Nxxxx to call me and reiterate the message that my only recourse is to file an appeal. I asked Dr. Nxxxx why Dr. Hxxxx would not speak with me directly and she said that she did not know, but could only give me the message that Dr. Hxxxx had passed along.
This is why I am now attempting to contact you, Dr. Hxxxx. As a customer of United Healthcare who is in good standing, I feel that I am receiving poor customer service. As a mother of a child with a severe disability, I feel that I am being treated in a callous and unsympathetic manner. At a minimum, Dr. Hxxxx should make the time to contact me directly and listen to my request. Her manner of responsiveness is insulting and unacceptable. Additionally, I do not feel that I am making an unreasonable request. My son’s BCBA is very qualified and has all of her credentials in order. I have no doubt that she will be approved for in-network status. By extending her individual contract for the brief period of time that it will take to get her approval in order (perhaps 12 weeks), this will prevent me from having to cancel my son’s therapy sessions or pay $2000-$3000 out of pocket to bridge the gap in coverage. It is not beneath me to beg on behalf of my son and his therapy treatments. He has been making very promising gains in ABA therapy over the last few months and it would undoubtably be detrimental for him to stop those services. I would also like to add that Lxxxx has reported that the contracted in-network rates that she will be receiving from UBH once she is approved is actually a bit higher than the individually contracted rates that she has been receiving. Therefore, it would not cost UBH any extra money to extend the contract with Lxxxx.
I would be extremely grateful if you would contact me directly so that we may discuss the possibility of just one more extension of Lxxxx’s individual contract so that my son may continue his therapy without interruption or undue financial hardship on my family. Please respond to this email or call me at your earliest convenience.
The grand-supervisor called me 10 minutes after I sent this email. She was as nice and friendly as she could be. She asked for the information to contact Gray’s therapist and said that she would set up a phone call ASAP. She said that she would do her best to help us because our request seemed reasonable. Four days later, she overturned the denial of our therapist’s contract and approved the extension. I’m back to paying nothing out of pocket through the end of the year.
The moral of the story:
Don’t give up. Don’t take negative outcomes from subordinates. I don’t think that the grand-supervisor was intimidated or annoyed my be. I think she genuinely saw my point and wanted to be helpful. The trick was climbing over all of the other obstacle-people who were thrown in my way.