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Private health insurance? Press 1 to be denied. Otherwise, hang up.

If Kafka designed a health insurance plan, it would be ... a lot like what we have.

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Consumers may be happy with the skill of their health care providers, but wind up unable to pay for the work if insurance doesn't provide expected coverage.

If Kafka designed a health insurance plan, it would be ... a lot like what we have.

When the envelope arrived in my office mail slot — I have a psychotherapy practice in Madison Valley — I felt a flutter of hope. But it soon died.

Instead of a check from a certain insurance company notorious for its reluctance to pay claims, let’s call it Darth Healthcare, what I found folded inside the envelope was a single sheet of paper.

“We received the above claim for [client name],” it said. “Before we can process it, we need information that was missing, invalid or illegible on the claim form you submitted.”

In a little box immediately below, the letter asked me to provide “the following information.” The following space was blank.

We hear a lot about the horrors of a government-run health care system, the supposed inefficiencies and restrictions. But while pundits panic about "death panels" and other hypotheticals, my clients and I are adrift in scary waters, fending off real attacks by private-sector pirates.

And the form I'd just received was a shot across the bows. I’d seen its like before. It was letting me know that a claim I’d sent off so carefully five weeks before by both FAX and the U.S. Mail, with all its i’s dotted and t’s crossed, and with a spare copy of my W-9 attached just in case they’d lost the three I’d already sent them, had failed to be accepted. My claim was in limbo, not rejected but not being processed, either. The closest thing I could find to an explanation was a code, “E8.”

What did “E8” mean? I had a free hour and thought I’d use it trying to find out.

First, I called the number the form letter advised me to call. This led to the usual round of recorded prompts, at which I punched in my tax ID number, my National Provider Identification (NPI) number, and my patient’s ID number and date of birth.

“For claims,” the recording said, “press 3.”

I pressed 3, and after a fairly brief wait I heard the voice of a young man whose accent gave me the impression he was African-American, who very helpfully spoke with me for about 15 minutes. During this talk of course I needed to give him again my tax ID number, my NPI number, my patient’s ID number and date of birth, and the service dates on my outstanding claims.

He said that “E8” meant that my forms were incomplete.

“What’s missing?” I asked. He paused. “Well, um...nothing, as far as I can see.” Pause. “I don’t know why they marked this as incomplete.”

I had heard this kind of thing before. The last time I’d called this insurer had been about a month earlier. That time, I’d been told that my claim had been marked as illegible (I think the code was “E4”), though the staffer on the phone was looking at my claim and could read my writing clearly.

The young man interrupted my reverie by offering to put my claim in for review. This would take up to 15 days, he said, and he gave me a confirmation number that probably had more digits than he had years of living behind him.

We were just about done, I thought, pleasantly surprised to see by the clock that only 20 minutes of earth time had elapsed while my young man and I were in cyberspace together. “Oh,” I said. “Before I go, could you please let me know about a claim that was put up for review about a month ago?” And I rattled off the confirmation number.

He went quiet for a minute or two while I waited. Then he was back. Was I imagining an ominous change in his tone? “One question,” he said. “Is this a medical claim or a behavioral health claim?” “Behavioral health,” I said.

“Well,” he said. “This is not the right number to call for behavioral health claims. This is medical claims.”

“Oh,” I said, impressed by the utter unforeseeability of this twist. “But the other claim we were talking about was also for behavioral health. ”

My young man, who was suddenly not my young man after all, gave me a different phone number, and then transferred my call.

Once again, I had to pass the ritual checkpoints: type in my tax ID number, my NPI number, my patient’s ID number and date of birth. The recorded voice then offered me a series of choices, none of which was “claims.” I listened again. “If you have received a letter from us, press 3,” the voice suggested. I pressed 3.

After a brief wait, a soft-voiced young man with an Indian accent greeted me. After we went through my tax ID number and the other numbers, I thought we were becoming old friends. But it was not to be. Five minutes into our conversation my new young man realized that he was not the person I was supposed to be talking to. He was not in the right department at all.

I admit I took it hard. But I tried not to show my shock, or the fleeting despair I felt at being abandoned so soon. “Will you please tell me which number I should call?” I asked, and was glad to hear that my voice was almost as blandly pleasant as the recording’s.

Another number. Maybe it was the right one, I thought hopefully, because it was not to be found anywhere in the form letter I’d been sent or, as far as I could find, on the company’s website. Maybe this was the secret, inner sanctum claims processing number, the one they gave you if you proved your worthiness by never having given up hope. I dialed. Another ritual entry: tax ID number, NPI number, and the like. “For claims, press 2.” “Please hold.”

I looked at the clock: 11:38. Twenty-eight minutes and counting. I wondered if I would have time to finish this call before my noon appointment. The recording asked me, pleasantly enough, if I would take a survey after my call. “No,” I said, hoping Darth Healthcare would not retaliate by vaporizing my claims.

Eventually, a woman with an eastern European accent answered. This time, I asked her name (Ria) and wrote it down carefully on the sheet of paper I keep in my patient’s file for this kind of information. “I was told this is the right place to call for claims for behavioral health services,” I said. “Is that right?”

Yes! It was. So far, so good. Ria’s and my conversation went on very much like the first conversation I’d had with the young African-American man.

Ria, too, couldn’t say why my claims were being held up. But I did find out what had happened to my June 9 claim review. “The reviewer said that the claim was properly handled,” she said.

“Do you mean it’s been denied?” I asked.

“No ... hmm. I’m not sure why they said it was processed correctly,” Ria said. She was quiet for a minute or two. She came back on. “I think I see the problem,” she said. “They didn’t have your information.”

“What information?” I asked, and heard my voice crack.

“Well, your tax ID number, and your NPI number, and your office address.”

I wondered how on earth they had sent me that form letter if they didn’t have my office address.

“I have sent all of that information in,” I said. “I have sent it in multiple times.” I paused. So did Ria.

“I’m sorry,” I went on. “I must sound frustrated, but I’m not blaming you for any of this and don’t mean to take it out on you.”

“That’s OK,” Ria said. “I understand.”

I tried again. “I have sent in information many times in response to hearing that my claims were being held up for lack of information; but no matter how I send it in, by mail or FAX or even directly on the phone, it doesn’t seem to be received. I would appreciate any help or advice you can give me in getting my claims resolved.”

Ria said, “Well, I think I see the problem. I think you’re not entered into our system.”

I hope I exhaled quietly. “When I called last, on June 9,” I told her, “I was told the same thing, and was also told that I was being added to the system then, during that call.” 

Ria said she would put in a request to have me added to the system. Then it was clear to us both that she had done all she could do, so we said goodbye.

“Have a great day,” she said, sounding as if she meant it, and I wondered what it was like to have her job. I was pretty sure I knew why her employer had recently paid a nine-figure settlement of a class-action suit by health-care providers. They had set up a system that guaranteed I would waste more time and effort trying to squeeze payment out of them than my claims were actually worth. Ingenious.

I had five minutes to get ready for my next appointment. I would have to wait until I had more time, and equanimity, to consider my options. I could ask my client to call her insurer about the claims or ask her human resources department for help. I didn’t want to do either of these things because one of the ethical boundaries in my kind of work is that the therapist is there to help the client, not vice versa — though this was an area where an ethical argument could be made on either side. I could also stop accepting her insurance. But that wouldn’t solve the problem that my client was receiving imaginary coverage in exchange for real premiums she and her employer were paying.

And it wouldn’t answer my larger dilemma, which is how to do my job in an industry increasingly prey to outright crooked practices by corporations.

Is this the future of American health care? I wondered. Only three years ago I thought we'd all have a public option, the same quality of health care coverage our president and Congress enjoy, which would raise the bar for all the competing private-sector plans as well. There was a noisy reaction, and the actual public option (as opposed to what was eventually approved) was defeated, which some people saw as a victory. But against the imaginary tyranny of "death panels," I see the actual tyranny of people paying their premiums in good faith and believing they're covered, finding out only at the worst time — when they're sick — that instead of being taken care of, they've been robbed.

  

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Private health insurance? Press 1 to be denied. Otherwise, hang up.

About the Authors & Contributors

Carol Poole

Carol Poole is a psychotherapist and writer who lives in Seattle.