A Glimpse Into the Bureaucratic Hell of Denying Health Insurance Claims

By Molly Osberg | March 7, 2018 | 4:30pm

Features

Over the last few months, the Trump administration has begun to dismantle the Affordable Care Act, offering short-term private insurance as an alternative. We thought we’d check in with some people who worked in the industry before rules around pre-existing conditions and mental health parity were enacted: people whose jobs involved daily management of strangers’ treatment, from an air-conditioned board room or an office building or a call center.

Interviews have been edited and condensed for clarity.

Jeremy Beckham, 33, insurance sales, Wisconsin

I was in sales between the ages of 19 and 21. I’d worked in other sales call centers, but the way the call center industry was, insurance sales was a higher-paying job.

When I was first hired—this is one of the top five insurance companies in the country—I had to go through a trainer and licenser program. I was licensed to sell health and life insurance telephonically in 26 states. I want to stress that even though I worked for this one company for two years, everything that happened there was very typical of the industry. I’m not trying to tar and feather anybody specifically. There’s barely one bit of difference between any of these companies.

So people would call and say, “I’m trying to get health insurance for me or my family or my kid,” and I’d try to sell them health, life, and dental, all individual plans. Part of that process is that you screen people for pre-existing conditions. There were three different stages of screening. The first thing, right at the beginning of the call, I’d ask a couple questions sort of off-the-cuff. Frankly, if I knew they were going to be declined, I was wasting my time talking to them.

So I’d ask, casually, whether they had a history of heart disease, diabetes, cancer, heart attacks. Kind of develop a rapport. That caught a pretty good chunk, diabetes especially. And I asked all that before I even made the sales pitch, so the phone call would be, like, two minutes long. If they got declined I’d tell them what other options they had, based on what state they were in. I had a computer terminal that told me what each state offered. Florida was pretty good. Some states had literally nothing, and that was pretty hard. All I could say is, call other companies, knowing they would decline them. Maybe I’d tell them to find employment somewhere with group health insurance.

But if they made it through those kind of off-the-cuff questions, we’d go to the application process. On the very first screen on my computer console, it listed something like 20 of the most common conditions that would cause someone to be declined. If they had any of those there was no point in going further. They were things like chronic obesity, pulmonary disease, chronic inflammation, ulcerative colitis. If at any point in your life you’d had a heart attack or a stroke, declined. Most forms of cancer, but not all. Pregnancy.

It was so routine to inspire deep anxiety in people.

For many people, this was not the first insurance place they called. They had already been declined. On our applications, there was a question that was like, “Have you ever been declined from another company?” But there’s so much uniformity; you either qualified with one of us or none at all. Pregnancy was an issue, too, though if you were single and pregnant you weren’t always up shit’s creek. Many of the states allowed you to get on Medicaid, which was almost always a better plan than what I was selling, anyway.

So after that list of 20 questions, we’d really get to the meat. It was like, a 45-minute phone call, maybe. Question: Have you or anyone on this policy ever had asthma? A history of osteoporosis? It was close to 100 questions. And after we completed it, I’d go to the underwriting department. They’d look at the application, and obtain people’s medical records from the Medical Information Bureau, and they had the final say. Sometimes they’d approve them cleanly, sometimes they’d flat-out deny. Or they’d approve you with a premium rate adjustment, like, we’re going to approve you but your BMI is too high and you’re obese so we’re going to give you a 25% premium rate increase.

Some things, like asthma, we’d approve you, but with a rider. If you need an inhaler, or an emergency visit for an asthma attack, we’d give you a policy that covers everything except that. People would be like, that’s the whole reason I wanted to plan! Sometimes the underwriter would uncover that the person lied to me, and I don’t really but every time you file a claim, all those insurance companies are sharing the information with each other. So that would be an awkward conversation I’d have to have.

There were horrible moments, fairly frequently. I got through it because you rationalize it in various ways. You know, I just work here at the call center, I don’t make the rules. But there was a lot of moral discomfort. I remember many times having to console people.

This is one of the strangest circumstances, but I encountered it a lot: Sometimes when a mother and father split up, it was common for the mother to get sole custody, and the father to be required by law to get insurance for the kid as part of his child support. If he violates that, he can go to jail, be held in contempt. But we screened children just as we screened adults.

I would get calls from these fathers, but the kid would have a condition: autism, obesity, diabetes. And we’d have to tell the father, “We can’t insure your son.” He’d be like, I’m going to jail. I’d maybe send an email or something, but even judges in our legal system did not understand you couldn’t just go out and get health insurance. I’d be like, “No one is going to insure this autistic son.”

I’d be like, “No one is going to insure this autistic son.”

One call I remember, we went all the way to the underwriter, and she got declined. It was a whole family: a wife and husband, and a couple of kids. I was dealing with the mother and one of the questions was about infertility treatment. Our plan by default did not cover infertility treatment. She said yes, I did have infertility treatment, but I don’t want it anymore. I’m done, I don’t want any more kids. She was still declined, and I called the underwriter. Here was the explanation: By law if you insure a woman and that women has a child, you are insuring the baby from the moment of birth. And women who have infertility treatments, research shows they have a higher risk of complications in pregnancies, babies with lower birth rates. So it’s riskier, but the idea was that since we don’t want to insure this baby that she’s never going to have, we’re not going to insure her.

It was so routine to inspire deep anxiety in people. I’m not exaggerating when I say a quarter of the calls I received were declines. If we get rid of the rules around denying people for pre-existing conditions, it’s going to go back to to that. I can’t believe how short our memories are, we’re going down the same fucking road. And what, expecting these companies to suddenly have morals. And even if you’re a shrewd capitalist, and think every business has the right to be concerned with the bottom line—what if you have diabetes? They’re just going to view you as a bad bet.

Adam Nikolai, 41, insurance company project manager, Minnesota

I started working at the call center right out of high school, in ‘99. But I had a pretty broad skill set so I advanced pretty quickly. It wasn’t as bad as you think—I’d worked in collections before that. But I ended up doing just about everything. Before I left I had moved up three levels as a project manager, which was top-level projects handling the implementation of new networks and new systems. I worked there until 2012.

Any time the company had a new initiative that they wanted to pursue, that was called a project. So whether it was a new type of policy that we wanted to create, or a new network partnership—if we wanted to partner with Aetna to access their doctors and hospitals, for example. A company is a massive beast, you need a person to kind of drive that and get all the areas that are impacted together. But any project manager will tell you 40 percent of their jobs is giving status reports.

The whole business is risk management, which was really drilled into us from the first day: It’s constant in the ambiance, from the corporate motto to the materials, from when you walk in the door to get trained to every time the CEO speaks in a big company meeting. I worked at a health insurance company that was based on the idea that it was a for-profit industry. And I don’t blame them for any of this stuff. It makes sense if you’re going to take an insurance policy and your goal is to make profit, you need to manage your risk and exposure. That’s where stuff like pre-existing conditions and underwriting and late payments comes into play. I think we need to make a decision as a nation whether we want health care to be for-profit or not.

I worked at a health insurance company that was based on the idea that it was a for-profit industry.

What’s interesting to me is that our CEO was very involved in the development of the ACA, he was out of the office all the time and we were getting all these emails with updates from him. He could get where people were coming from, with all the hate around pre-existing conditions and lifetime maximums. But we couldn’t get rid of those things because then we’d only have sick people, and we’d go out of business. That’s just how the math works. So the flip side of that is, you know, if we’re going to get rid of all those things, we need to expand the pool and we need to have everybody involved. We need to have everybody insured. And for those of you paying attention at home, that’s exactly what happened. And yet within a year or two the message from on high was, “Oh, we hate the ACA now.”

Honestly a big part of the reason I think we didn’t get involved in the first year is because they weren’t sure exchanges were going to exist the next year because the ACA was under constant assault. The House was trying to repeal it like four times a week.

I didn’t get into the nitty gritty of individual claims. But—and I don’t think a lot of people get this—it’s not like people in health insurance see the insured as faceless entities. There would be some very passionate arguments on the inside when a claim was denied and people appealed it, or when we thought a person was suffering. There was a way to interpret a contract in a way that would pay, rather than not pay.

Within a year or two the message from on high was, “Oh, we hate the ACA now.”

A lot of the time it was around inpatient hospital bills that run into the hundreds of thousands of dollars. Or emergency room bills. And we didn’t have mental health parity at the time, so if someone went in to the emergency room for an anxiety attack, we’d have to figure out if it gets covered as an emergency benefit, which is really generous, or as a mental health benefit. It’s a good example, because people would think they were having a heart attack. And then boom, the doctor says you’re having an anxiety attack, and it’s a mental health issue, and there isn’t coverage so that’s $500, sorry. That argument would come up fairly often and it wasn’t always decided the same way.

When the ACA first came out, I thought it was a fantastic idea. I thought it was a very American approach to the idea. But then I saw all the sabotage and the undercutting, just ridiculous claims about socialism and death panels and just this constant whining. They did everything they could to get their political point across and they’re literally killing people. So at this stage of the game I’m a single payer guy, full stop. We tried to do it the American way. That didn’t work, so let’s do it the Canadian way.

Amy, 42, medical billing and claims, New York

I worked as a biller for a few doctor’s practices, about 15 years ago. And before that I worked processing claims for a local medical insurer with about 100 employees. I really only worked for the insurer for about a year because it was getting a bit soul-crushing listening to people cry on the phone when I would deny their claims. But that was the job. Deny if at all possible. Pre-existing conditions were a big, big thing then. We would deny anything if we felt we could get away with it. I hope that’s better now than it was, years back.

People’s coinsurance would be so high, they couldn’t keep up with the bills. And it was my job to inform them we couldn’t treat them anymore. That was horrible because I was talking to very sick people who needed care. I got tired of being the bad guy in that regard so I had to leave that line of work behind.

But that was the job. Deny if at all possible.

Later when I worked in billing at a small doctor’s practice I could spend hours trying to work on a single claim. It just wasn’t cost-efficient, dealing with private insurance. Most of the doctors I worked for were having trouble making payroll. The practices I worked for each had five or six physicians who were also surgeons. The Medicare claims were really what was keeping the doors open. Medicare is easy: treat the patient, check a box, get paid. No hoops to jump through.

I didn’t really deal with patients by that point. It was just me in a cubicle on the phone arguing with Blue Cross. They would deny for the most ridiculous reasons. Their favorite game to play was to ignore my numerous claim submissions. Then once the filing date passed they would tell me I missed the filing deadline even though I could prove I had submitted it several times on time. They just don’t want to pay.

Most people believe doctors hate Medicare, when in fact they love it. Claim-filing and payment is easy. They didn’t even mind taking slightly smaller fees because their administrative costs were so much lower. You’d be hard pressed to find a doctor who doesn’t take traditional Medicare. Not so much with the Advantage plans. Dealing with them is pretty much like dealing with private insurance.

Which is why I hate private insurance with such a fiery passion. It’s an evil business. It’s not just patients being hurt. It’s doctors, too.

Jennifer Johnson, 56, contract negotiator, West Virginia

I negotiated insurance contracts for a hospital and health care system in West Virginia for 15 years as the director of strategic services. My husband’s a consultant in the pharma industry. We’ve kind of been in health care all our lives.

My dad was an orthopedic surgeon, so I helped in his office and actually I remember the days when I was a teenager where you had to hand-write all the insurance bills. Just to submit. I learned really from the ground up. I’ve billed insurance. I’ve called insurance companies. I moved into negotiation. I was in charge of the marketing department, as well.

I left the whole industry because of troubling moments when I really felt I’d lost my soul.

I think the big thing people don’t understand about commercial insurance is that, unlike Medicare, which has decided what a fair price point for something is, the individual insurance companies look at our case mix—what kinds of specific surgeries we do on a daily basis—and decide how much they’re going to pay. So one company might say, for a knee surgery, they’ll pay $7,000. Another will say they’ll only pay $5,000. I negotiated big contracts like that about every year. We used to negotiate a lot with PEIA, which is a health insurance company in West Virginia. You might have heard that the teachers walked out.

We were a private hospital and a non-profit. We had a cardiac center. Because we took a lot more critical care patients, those negotiated rates might really go down on something like cardiac care. Companies don’t want to pay the big bucks for that. A lot of it made no rhyme or reason. A lot of it was like, okay, if you guys aren’t going to pay for cardiac, then you’re going to pay for these other procedures, like outpatient orthopedic, where we can get people in and out quickly. It was like a game to figure it out: getting into specific codes for specific procedures line-by-line. We had our little cubby with our computer and a shelf of books, everything you need to know about Medicare, Medicaid, PEIA, workers comp, how to bill all these different insurance codes.

I worked for the chief legal officer, so it was myself and him. But they pulled me into the negotiations a lot because that was my strength. But it was mostly executives that would sit in in these meetings with the insurance companies. And it was just horrid. I was also on the executive board of a charitable foundation, and I left the whole industry because of troubling moments when I really felt I’d lost my soul.

We were advocates for people who didn’t have health care, the homeless. So if someone came in and had heart surgery and they were on Medicaid or they didn’t have insurance, we’re write off a good portion of the bill or set up payment plans. But even being a private non-profit charitable hospital some of the decisions that the executives made about who is going to get care and who is getting treatment, from a charity perspective, it was just horrible.

The focus was always to expand, and on profits. Working with insurance you get calls from people just crying: I just got my bill, I can’t pay this. And there was a process, patients would sit down with our financial services and go through their paychecks and things. But sometimes I swear people were denied simply because the executive director in the billing department didn’t like the tone of the person on the phone. And you know the executives got huge bonuses, enough to buy a car. And people are not getting the health care they need.

The focus was always to expand, and on profits.

All my friends are still doctors in West Virginia, and Obamacare really was a good thing; the bad thing was that doctor’s weren’t paid as much. I left when we moved to Europe; my husband had been flying globally and having me working full-time just wasn’t working anymore. And I started coaching tennis when we moved to Switzerland. It’s always been a passion, tennis. But Switzerland is really the gold standard for health care. I was really impressed when we lived in the UK, too: I had no problems, I could see my general practitioner any time same day within 24 hours. Specialists took a little time. Sorry if I’m rambling!

It was really heartbreaking, working in West Virginia. It was a university town, so it wasn’t exactly like what you think of as down-home Trump’s America. But you still had coal-miners coming in with lung cancer. The mission is to help as many people as you can. That’s why we’d do community health fairs, raising awareness. But, you know, it’s the insurance companies. They have all the power, really.