The couple’s daughter, Violeta Rivera, died on Nov. 7 as a result of a severe form of epilepsy called Dravet syndrome, which was caused by a genetic mutation.
Violeta spent the last four days of her life in the ICU.
Weeks later, her parents received the $58,000 bill for the ICU stay, which still had not been covered by their insurance provider, Anthem Blue Cross Blue Shield.
“We thought we had good coverage,” said Austin Rivera.
The complexity and uncertainty of health insurance, including the difficulty of navigating the system and fighting for claims to be covered, is an experience known to many Americans. Nearly one in five, or 18%, of insured adults experienced a claims denial within the past year, according to KFF, a health policy and research organization.
Credit: Jim Noelker
Credit: Jim Noelker
Most consumers (69%) with denied claims don’t know they have the right to appeal those decisions and even more (85%) don’t try to, a KFF survey says.
The Dayton Daily News found people in the region struggling with trying to get insurers to follow through on medical claims.
“Navigating the complexity of health insurance and bills from medical providers can be very stressful, especially if you’re sick or a family member is in crisis,” said Amy Rohling McGee, president of the Health Policy Institute of Ohio.
Health care providers also told the Dayton Daily News they face challenges securing contracts with insurers to make sure their services are covered.
Lack of help in claims process
The Rivera family’s claim was paid in December during the reporting for this story. This followed weeks of the family trying to find out what they needed to do in order to get the claim covered with little help and no roadmap.
“We are deeply saddened for the Rivera family, and our heartfelt condolences go out to them during this difficult time,” a statement from Anthem says.
Additional information was needed in order to process the claim, according to Anthem, which received authorization from the Rivera family to talk with the Dayton Daily News about the medical claim.
Anthem provided a timeline to the Dayton Daily News that included when the company sent letters to the Rivera family, but the first letter in reference to the additional information that was needed came more than a month after the ICU stay took place and after the claim was made.
The letter from Anthem was also sent after the family had already received the $58,000 hospital bill. This made it look like the family owed that amount and that Anthem had not covered the claim as Anthem had already covered other items on the bill in addition to the $58,000.
“It’s like they evaluated it, decided to cover a portion of it, a small portion, and then didn’t cover the other portion,” said Court, who showed the bill to this news organization. The family also showed a letter from Anthem giving them prior authorization for their daughter’s stay in the ICU.
While Anthem has said the claim for their daughter’s ICU stay was “pending” during that time and not officially denied, it was something that was not effectively communicated to Court and Rivera, who thought they had been left with a $58,00 bill not long after losing their daughter.
“If this was simply a matter of needing additional information, one of the many Blue Cross Blue Shield customer service representatives or nurse case managers should have communicated that to us during the dozens of hours we spent on the phone with them,” Court said.
Continuing struggles
Court and Rivera have been trying to have another child through in vitro fertilization (IVF) so that way they can do genetic testing to make sure their future children are born without the mutated gene that causes Dravet syndrome. That process is being met with delays in getting coverage approved due to the limited number of clinics available in the U.S. that provide the genetic testing services.
“We still feel like we’re living in a nightmare,” Court said. The loss of their daughter still haunts them, she said.
When the grief becomes overwhelming, Court and her husband tell each other they’re “in the hospital” again, and they instantly understand what the other is feeling.
“We know that it means that we’re having flashbacks to those four days of our child going from perfectly healthy and normal to brain dead,” Court said.
Providers face frustrating delays
Health care providers are also struggling with insurers, including when the services should be covered through Medicaid programs.
When Abbey Osborne, owner of Engaging Days Senior Enrichment Center in Englewood, was trying to set up her contracts with Medicaid Managed Care providers for the PASSPORT Medicaid Home Care Waiver program, she kept hitting a wall when it came to getting her contract set up with Molina Healthcare.
Osborne, who is already authorized to provide PASSPORT services, has to reach out to health plan providers to establish contracts with them. While one insurer had the contract approved within a day, Molina took months, she said. The contract was only recently approved.
Credit: Jim Noelker
Credit: Jim Noelker
The PASSPORT program helps Medicaid-eligible older Ohioans get services and supports they need in order to stay in their homes or other community settings, rather than enter nursing homes, according to the Ohio Department of Aging.
Services available through PASSPORT include assistance for personal care, adult day care, independent living help, medical transportation, out of home respite and more.
“The main issue was that once I submitted that (contract to Molina), I called and called and called to check on the status, and no one could ever find my information in the system. No one could ever find proof that I ever sent it. I got bounced around all the time. Every single person I spoke to on the phone, not one could help me,” Osborne said.
Osborne reached out to people at Molina over email, and if she got a response at all, she was consistently told that she had contacted the wrong person, Osborne said.
During that time, she had a client who was a Molina Healthcare member waiting to get services at Engaging Days. Osborne decided to provide her client those services for free while trying to get her contract approved with Molina.
“If I had left her to wait, she would still be waiting for services,” Osborne said.
Osborne eventually found the correct contact at Molina and got her contract with Molina approved after repeatedly calling and emailing to make sure that the contract was moving forward.
“Especially for our seniors with dementia, your company, your health care, should be making sure that your needs are met,” Osborne said.
The Dayton Daily News reached out to Molina Healthcare for a comment. The health insurer has not responded.
Fighting for coverage
If a patient or family gets a medical claim denied by their health insurance, there are steps they can take to challenge that decision. First, they should reach out to their medical provider’s office to make sure the claim had the correct billing codes and ask the doctor’s office if they can resubmit the claim, Rohling McGee said.
“Asking questions patiently and persistently, documenting all calls and correspondence, enlisting a family member or friend to help, and appealing the decision are all helpful practices or steps to take,” Rohling McGee said.
Under the Affordable Care Act, insurers must provide enrollees with an internal review of adverse benefit decisions and the right to an external, independent appeal.
If people are still unsuccessful with getting their claims covered, the Ohio Department of Insurance contracts with independent review organizations to conduct its own appeals.
Consumers can file a complaint on an insurance company with the Ohio Department of Insurance by visiting insurance.ohio.gov. People can also request a complaint form and instructions for filing a written consumer complaint by contacting the department’s consumer services at 800-686-1526.
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