First in a series of experience and tips on how to advocate for your child or yourself with your medical insurance provider. This outlines our health insurance complaint and what happened next.
We had been Group Health members for over 20 years, and had always been pleased with the quality of care and commitment to patients as a partnership. When our daughter was born with special needs, this partnership approach did not change. To the contrary, she was always treated with respect and value, with a focus on doing what was right for the patient. The times that I did have a concern, a simple call to customer service or a conversation with her primary physician got things back on track.
Since Kaiser Permanente merged with Group Health in 2016 there has been a significant change in the business side of what is now Kaiser Permenente, Washington. Now, when there is an issue, I find myself in a never-ending bureaucracy that acts like it cares, but in reality puts me through an endless loop where complaints are not heard and action is not taken.
Whether inefficiency or intentional, the result is a process that is wholly ineffective and wearing for the consumer.
I was in that place a year ago and ended up having no choice but to file a complaint with the Washington Insurance Commissioner; the findings were in our favor, but I still had to fight to get Kaiser to pay the entire bill they owed.
In August 2016 our family set out on an epic road trip taking my oldest to college across the country. We had so many fun plans for the trip, so many sites to see together as our family was entering a new season of life.
My youngest daughter has special needs, among them restrictive lung disease. We work very hard to keep her healthy in a variety of ways, but on this trip we would see how quickly things can change. What started out as a little wheezing from asthma due to wild fires, turned in to a life threatening condition that required hospitalization. You can read more about that story here.
After she had fully recovered, I started checking in on the hospital bills. It was clear there was a problem, her bills were being marked as “not covered.”
This made no sense. Our plan included coverage at that hospital, something that I confirmed with Group Health/Kaiser Permenente when my daughter was in the hospital. In fact at that time customer service quickly verified that over the phone.
But now the story had changed. I pulled up my benefits booklet and confirmed what I already knew to be true; the hospital was indeed in network. Based on my past 20+ years with Group Health, I was sure that a phone call would resolve the issue. Boy, was I wrong.
I ended up spending the next 9 months contacting Kaiser Permenente regularly, where the conversations would all go the same way with a different story on why the bill wasn’t being paid. They told me that we hadn’t met our deductible (we had), that it wasn’t in network (it was) and that there is no max out of pocket for my policy (there is, and in fact we had surpassed it 2 months prior). During each conversation I spent a lot of time on the phone explaining that, yes, we had met the deductible, yes in fact we were at max out of pocket, and yes, the hospital is in network, showing them where on the Kaiser Permanente website and showing them our policy. They would put me on hold for sometimes up to 10 minutes. One time they tried to mislead me using my 2017 policy, which I corrected them. They said the complaint had been escalated, but I never hear back. Every conversation went the same way, ending with, “You’re right, we’ll reprocess this and get it paid,” including our last conversation on June 23, 2017. Finally, I sent a letter to the president of Kaiser Permanente Washington, Susan Mullaney, but I never got a response. We were lost in the system and nobody either cared or could fix it.
Then I received a letter from the hospital stating that I was going to be sent to collections in 7 days if payment was not made. It was such a clear-cut issue and the runaround I was getting from Kaiser Permanente was so insane, I began to feel like my daughter was being singled out for having special needs.
By this point I had absolutely no confidence that Kaiser Permenente was going to meet their contractual obligation and decided to file a complaint with the Washington Insurance Commissioner. The process was very straight-forward. There is a deadline enforced by the State and our resolution came quickly, albeit with some residual push back from Kaiser Permanente.
Here is our correspondence through the Washington Insurance Commissioner during that complaint. Personal information has been redacted.
On July 6, 2017 I submitted this letter stating my health insurance complaint.
On July 24, 2917 I received this response from Kaiser Permanente, where they completely changed the story and added a $50 co-pay to me. There was no reference to the balance owed being paid.
On August 3, 2017 I replied with this letter, explaining that Kaiser Permanente had not only changed their story in their response, but still hadn’t paid the full balance that they owed. I brought in specific conversations with names and dates, because I always keep notes of conversations, one of those conversations happened to be recorded.
On August 25, 2017 Kaiser Permanente responded with this letter, again they had excuses, but at least this time the entire balance due was paid.
I hate this stuff.
Some people might thrive on the fight, but for me it’s something that I take on out of necessity. I fight every day to keep my child healthy and provide a great quality of life; I shouldn’t have to fight with our health insurance provider to meet their contractual obligation. My special needs child cannot speak for herself, I promised her that I would always be her voice.
I hope that you or your child don’t have serious medical needs, but if you find yourself in that place, and your insurance company is giving you the run around, know that there is a solution in your Insurance Commissioner.
Here is the link to the Washington Insurance Commissioner’s website.
If you are located in another state you can find your Insurance Commissioner with a quick Google search.
Do you have experience to share? Let me know how it got resolved in the comments below.
