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An Impatient reader's saga: Figuring out where to turn when things 'get funky' with your insurer



"I’m writing to you because I’m extremely frustrated and I’m not sure where to turn for help," wrote one reader, whose sister is caught in the insurance labyrinth.
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A few weeks ago, I received an e-mail from Impatient reader Will Allen: "I'm writing to you because I'm extremely frustrated and I'm not sure where to turn for help."

The situation is not a two-sentence story, he said, it's a saga. Here goes:

Three years ago, Will's 42-year-old sister Betsy fell 15 feet through a hatch on a boat, fracturing her hip and traumatizing three vertebrae in her lower back. She's been in chronic pain since then; she's been to the emergency room twice in the past eight weeks.

"They basically just shoot her up with morphine and send us home, so the time for surgery is upon us," Will Allen said.

"Things get a little funky" 

"This is where things get a little funky," he said. His sister's primary care doctor retired in August 2013, and a new doctor bought the practice. She continued seeing the new doctor, but just learned two months ago that this doctor is not covered by her insurance, United Healthcare.

"So before the insurance company will move forward with anything, they expect her to pay for all the back visits that she has had to this doctor AND since she was seeing a pain management specialist (that she was originally referred to by her original doctor) but did not receive proper authorization from a new primary care doctor… she must pay all those back charges as well," Will Allen said.

Betsy Allen and Will Allen's son Spencer

Betsy Allen and Will Allen's son Spencer (photo courtesy of Will Allen)

His sister's in pain, he said, but the stress of dealing with this health care debacle has been excruciating.

She's now seeing a new primary care doctor, who requested two authorizations - one for an MRI, and the other for her to be seen by a surgeon. When I first heard from Will, they'd been waiting almost two weeks for these authorizations.

"Is there an agency we can turn to, to help us navigate through all this bullsh*t?" he asked. "Sorry, I was trying to think of another word... but that one really does a good job of summing things up."

"Who do we turn to?" 

"Who do we turn to when the people we’ve charged with taking care of us don’t?” he asked.

I referred Will to the Department of Managed Health Care, and asked him to let me know if the situation improved. A few days later, I heard back from him.

Someone at the department gave him some advice, he said: "They instructed us to call the health insurance company and tell them that we wanted an 'expedited review' and while we're on the phone with the insurance company, we should say, 'I know you have 72 hours to do the review, when does the clock start ticking?'"

Allen was also instructed to call the Health Consumer Alliance, if the situation wasn't fixed in 72 hours.

His sister called the insurance company and tried using that language. Still feeling frustrated, he ended up calling the Health Consumer Alliance before the 72-hour window was up. He said the woman he spoke with "really made me feel like we finally had someone on our side."

Betsy Allen recently - finally! - received the two authorizations she's been waiting for.

"I'm not sure if all the b*tching and moaning over the last five or six weeks is what brought them on?" Allen said. "Or if the term, 'expedited review' and the knowledge of the 72-hour time frame got them moving… but I think it’s the latter.

"We aren’t out of the woods yet, but we’ve made progress," he said.

Allen  added that there are likely to be more chapters to this saga: On Tuesday he plans to formally file an insurance complaint, with the help of the Health Consumer Alliance. And, he said, "one of the things in the back of our minds is that my sister is covered through a COBRA policy that expires in July."

Have you felt lost navigating the health insurance labyrinth? Tell us about it in the comments section below, or e-mail us at Impatient@scpr.org.