As I navigate the financial strains of therapy and doctor appointments for Gray, I am constantly bumping up against our insurance company. It reminds me of the courtroom scene from John Grisham’s movie “The Rainmaker.”
Q: Well, let’s talk about this mysterious section U. Why don’t we explain it to the jury. Take a look at it. Just read paragraph 3.
A: (reading) Claim handlers are directed to deny all claims within three days of receipt of claim. No exceptions.
Q: Now how do you explain this section U?
A: Well, sometimes we get some frivolous and fraudulent claims in our business. And sometimes we have to use this kind of language to focus in on the legitimate and more needy claims.
Q: Mr. Keely, do you honestly expect this court to believe that explanation?
A: Well, this chapter merely denotes in house processing guidelines.
Q: In-house processing guidelines? No, Mr. Keely, no it does not. Section U does a lot more than that.
A: I don’t think it does that, son.
Q: Mr. Keely, doesn’t it explain how claims should be rerouted and shuffled and rerouted, anything to avoid payment?
A: I admit nothing.
PL atty: Your honor, approach the witness?
Judge: You may.
Q: (Baylor hands Keely a huge book.) Now Mr. Keely, how many policies did great Benefit have in effect in the year 1995?
A: I don’t know but let’s see–
Q: Does the figure 98000 sound correct, give or take a few?
A: Maybe, that could be right, yeah.
Q: Thank you. Now of these policies, how many claims were filed?
A: Well, I don’t know that.
Q: Does the figure of 11,400 sound correct to you, give or take a few?
A: That’s about right, but I’d have to verify it, of course.
Q: I see, so the information I want is right there in that book? Can you tell the jury, of the eleven some-odd thousand claims that were filed, how many were denied?
A: Well, I don’t think I could. That would take more time.
Judge: You’ve had two months, Mr. Keely. Now answer the question.
A: Well, I, I don’t think (shuffling through book) Uh, 9141.
PL atty: 11462 filed, 9141 denied
That about sums up my experience with the insurance companies. They deny the claim first and then wait to see if anyone protests. In the early days, I would set aside about 90 minutes each week to argue with my insurance company. It was a maddening time-suck and often ended up with me in frustrated tears after requesting to speak with supervisors and enduring up to half-a-dozen transfers per call. I would marvel at the effort they would put me through. Occasionally, I would find a sympathetic representative and I would convince them to give me their direct contact information so that I could send my botched claims to someone who new what I was talking about. In the end, I would always get my claims paid, but I mourned for the other families in similar situations who likely did not have the same success I did. After all, I was a physical therapist who had spent my career fighting with insurance companies on behalf of my patients. I understood terms like “in-network,” “out-of-network,” “deductible,” “co-insurance,” and “pre-authorization.” I had armed myself with the Texas state law (House Bill 1919) that was originally written as a brain injury bill but had a section in it called the autism mandate that forced insurance companies to pay for behavioral therapy and nullified limits on speech, occupational and physical therapy for children who had an autism diagnosis. I had a copy of this mandate saved in my email so that I could send it or reference it whenever I needed to enlighten the person I was fighting with. What in the world were other families doing who did not have the information or the time to fight or the fortitude to reject the constant denials?
Over the years, the fight has gotten easier. Autism is twice as prevalent as it was 6 years ago (the frightening truth of that is best saved for another post). The insurance claims have, no doubt, followed this trend. Now, my insurance company has assigned me an “autism care advocate” in an effort to streamline these claims and keep track of their veracity. I can say now that I can go for many weeks without having to correct an insurance error and those that do require correcting only take up 15-20 minutes of my time. I have been feeling more comfortable with the process…until 2 weeks ago.
Gray’s behavioral therapist is a private practitioner who has worked with him for over 2 years. Because there were not a lot of “in-network” behavioral therapists when we started with her, the insurance company worked out an individual contract agreement with her. That means they negotiated her rates to their in-network standards and she had to file her reports with them so that she could get approval for the number of hours she could work with him each week. This was more work for her and less for me, but she took it on.
Last month, his weekly hours were up for re-approval. She filed all the paperwork and had a phone conference with the “peer reviewer.” (I love this term. It implies that the person on the other end of the line is a peer professional. Of course, they have similar credentials, but the fact remains that they work for the insurance company. After the review process was over, they decided that Gray did not qualify for the 20 hours per week that he had been receiving and dropped his allotment down to 15 hours per week. Never mind the evidence that showed he has been making progress (at a snail’s pace) and, therefore, really needs more therapy instead of less. We began the appeals process. This is in spite of the fact that my autism care coordinator told me that the decision was beyond appeal. In essence, she said “Here is an address you can write to. It won’t help, but at least you will feel like your complaints were heard.” Thanks. I needed a way to spend my extra time.
Then, two weeks later, Gray’s therapist told me that she had just received word that the insurance company was not renewing her individual contract and she would no longer be considered in-network. Of course, no one from the insurance company notified me of this. Of course, I was given no notice to consider my options. I called my autism care advocate to ask what was happening. He told me that the insurance company had more in-network providers now and they were trying to move their customers over to these bigger companies instead of using individual contracts. I told him that was all fine and good for new customers who had never worked with a therapist before, but kids with autism need consistency. It would be a horrible backslide to make Gray re-establish himself with a new set of therapists. I told him that I didn’t understand why our therapist’s contract had to be cancelled when it was causing no extra cost to the insurance company…she was billing the same as their in-network providers and she was submitting all paperwork according to their standards. I explained that this would not only be a disruption to Gray’s care, but it was a monumental task for me to search out a new provider whose schedule would match Gray’s availability. As I felt the tears welling up, I explained that parents like me have enough on our plate without having to spend our time arguing with insurance companies. He told me he understood because he has conversations like these everyday. I asked him, “You tell people that they have to flip everything over in their child’s life everyday? Your job title is ADVOCATE. Do you know what that word means?” When I asked if I could speak with his supervisor, he denied me access to her contact information and said he would send her a message to see if she might be willing to talk to me.
So, for the next 3 days, I called him and made him spend about 30 minutes on the phone with me as we rehashed the discussion above and I asked when I could expect to hear from his supervisor. Each time he denied me her contact information, but in our last conversation he gave me her name. I hung up the phone and called the main number for the insurance company. I explained to the person on the line that I had just been talking to <<supervisor’s name>> in the autism coordination department and our call was cut short. I asked if she could connect me to her directly and give me her extension to continue our conversation. It worked! Moments later, I was leaving a message on her voicemail that was lengthy, detailed and firm.
The next morning, I received a phone call from my autism care advocate. He informed me that he had been reviewing Gray’s case with his supervisor and they decided it would be in his best interest if they extended the contract another 6 months. They also encouraged my therapist to apply for in-network status so we could avoid this problem in the future. I thanked him for being so helpful and asked him to thank his supervisor as well.
Victory. For now. Now, how about that reduction in his weekly hours…