Health insurer denies 273 claims at once, sticking the patient with the bills
A Blue Cross health plan paid a patient’s medical bills for years and then pulled a reversal, clawing back the reimbursements. This newsletter’s paid subscribers helped hire her patient advocate.
What’s worse than your health insurer denying a claim?
How about your insurance company denying 273 claims at the same time, leaving you on the hook for $42,546 in medical bills.
That’s what happened to 41-year-old Stephanie Christy of Wilmington, North Carolina. Stephanie had been covered from 2018 until mid-2021 under an individual health plan sponsored by Blue Cross Blue Shield of North Carolina.
The story of how she lost that coverage illustrates the unique cruelty of the American health care system.
Stephanie has suffered for years with chronic migraines and other ailments and is unable to work, so she applied for disability coverage under Medicare.
The good news is that Medicare granted her coverage in the summer of 2021.
The bad news is that Medicare backdated its coverage to 2018.
That gave Blue Cross Blue Shield of North Carolina an opportunity. Blue Cross now considered Medicare to have been the primary payer going back to 2018. Thus, the insurer clawed back the money it had paid to Stephanie’s medical providers – 273 bills from 2018 until mid-2021. That meant Stephanie’s doctors, physical therapists, her nutritionist — all those medical providers who had cared for Stephanie and had been reimbursed under her Blue Cross plan — were now left with nothing.
Also, Blue Cross did not return the premiums Stephanie paid over this time period. And there’s no evidence that it repaid the taxpayer subsidies it received, which Stephanie qualified for under the marketplace plan.
Blue Cross did send Stephanie a 32-page Explanation of Benefits showing the cancelled claims. But Stephanie’s bouts with her headaches are severe and can go on for weeks. Sometimes she is so sensitive to light, smell and sound that she throws up and has to cut herself off from the rest of the world. Her eyes get blurry so it’s difficult to read bills and insurance company documents. She lives alone with her mother, who she cares for, and often she’s just focused on making it through the day.
Stephanie started getting flooded with medical bills and phone calls from billing departments. That led to collections notices and calls from debt collectors. The attorney who handled her Medicare disability case didn’t help with the medical bills. Neither did Medicare or Blue Cross, she said. She didn’t get any help until she Googled patient advocates in North Carolina and got connected with Marilyn Whitley.
My book, Never Pay the First Bill, and my health literacy videos based on the book, The Never Pay Pathway, are tools to help patients help themselves. But sometimes patients are too sick to handle things themselves, or the situation is too complicated. That’s when I recommend that they hire a paid patient advocate like Marilyn, to help make sense of the madness. I’m proud to say that the paid subscribers to this newsletter helped pay Marilyn’s fee in this case. As you may know, my newsletter is free, but I encourage people to become paid subscribers. Then I donate 100% of the proceeds to educate patients and to hire patient advocates to help people like Stephanie.
I’ve hired several advocates so far and will report on the cases as they become resolved, so this community can see how the donations are being used and, hopefully, more people will be encouraged to become paid subscribers. I’ve also donated to The Care Partner Project to fund future patient advocacy work. If you or someone you know needs help paying for a patient advocate, please contact me at firstname.lastname@example.org. Perhaps we can help!
Marilyn is a registered nurse with almost 30 years of experience working in health care, including at the executive level in hospitals and surgery centers. She runs Whitley Patient Advocates with her husband, David. In March 2022, Marilyn drove four hours to Stephanie’s house to pick up two boxes of bills and paperwork, to unravel the twisted mess of benefit plans, denied claims and medical bills. She discovered the Explanation of Benefits from Blue Cross Blue Shield of North Carolina that showed the 273 claims had been rejected in January 2022. “They rolled back 100% of the claims,” Marilyn said of the insurer. “This is an injustice for Stephanie. She didn’t do anything wrong. She’s entitled to health care, and she should not have to go through this duress to figure it out.”
Marilyn has contacted each medical provider to urge them to resubmit their bills to Medicare. Most of the claims have now been paid but it’s a challenge to keep it all straight. Sometimes Marilyn and Stephanie think they’ve got the situation covered and then another bill arrives that’s been sent to collections. Marilyn estimates that there’s still more than $10,000 to be reimbursed.
I wanted to get Blue Cross’s side of this story, so Stephanie waived her HIPAA privacy rights so the insurer could answer my questions. The insurer said in a statement that its action falls under what insurance companies call “Coordination of Benefits.” “Coordination of Benefits means that if you are covered by more than one insurance plan, benefits under one plan are determined and paid before the second plan's benefits are determined and paid,” the statement said.
That makes some sense, but “Coordination of Benefits” is some lame insurance-speak for what’s going on here. Marilyn and Stephanie said no one from Blue Cross Blue Shield of North Carolina reached out to Stephanie to help coordinate all her denied claims. Marilyn said that the EOB that showed all the denied claims was not accompanied by a letter explaining the situation or showing Stephanie where she could call for assistance.
I asked Blue Cross to explain what it had done to assist Stephanie. The insurer said its records show Stephanie called, but it did not say if anything was done to assist her. “We sincerely apologize that we were not able to provide more education on that date,” the statement said, adding that she should try and call again.
I also asked Blue Cross whether the premiums and taxpayer subsidies would have been less for secondary coverage than they would be for primary coverage. It seems that some refund for reduced coverage would still go to Stephanie and the taxpayers who paid for her primary coverage only to receive secondary. Blue Cross did not answer that question.
“Coordination of Benefits” is a common insurance industry practice. Sadly, patients can easily be caught in the middle. Blue Cross Blue Shield of North Carolina has a noble motto posted on its website: “We Resolve to Make Total Health a Priority.” That rings hollow when its actions harm its members’ financial health and emotional wellbeing.
Thankfully, Marilyn is on hand to help Stephanie, and we have generous subscribers to this newsletter who have helped pay the tab. Stephanie said she’s been “blown away” by the support. “I need her help so much,” she said of Marilyn. “I’m so thankful for everybody.”
Do you need help paying for a patient advocate, or know someone who does? The donors to this newsletter have been generous, and I might be able to help. Reach out to me at email@example.com.
Want to help patients like Stephanie? Please consider becoming a paid subscriber to this newsletter. I donate 100% of the proceeds to educate patients and hire advocates for patients who need them.
Let’s keep paying this forward. People are getting buried by confusing medical bills and medical mishaps. Please share this newsletter so they know that help is available.
I love to see working Americans have their mindset flipped by effective health literacy education. Our health care system isn’t broken. It was designed this way. It’s no accident that employers and working Americans keep paying more than they should for health care. But employees are not powerless.
Does your organization sponsor health benefits for your employees?
Want to see them get equipped to be savvy health care consumers?
I’m looking for bold employers to equip their employees with my Never Pay Pathway health literacy videos. They’re based on my book, Never Pay the First Bill, and the knowledge will transform the way your employees engage the health care system.
The videos are an ENGAGING resource that will save money for your employees, their families - and your health plan. Let’s stop overpaying for our health care, shall we? Email me at firstname.lastname@example.org for more information.