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Health insurer tries to avoid owning up to error

October 21, 2009|DAVID LAZARUS

Who should pay when a health insurer screws up? Not the insurer, apparently.

Seal Beach resident Kelley Barton wanted to be sure that a treatment would be approved by Anthem Blue Cross when she sought medical care last year for her 14-year-old son, who had suffered from chronic constipation since he was a little boy.

"I wouldn't even schedule the procedure until I knew it was covered," Barton, 51, told me. "I knew it probably wouldn't be cheap, and I didn't want to have to fight about it with my insurance company."

The procedure in question was a biofeedback technique involving sensors and muscle training to help Barton's son. Studies have shown that biofeedback is an effective remedy for chronic constipation.

But Barton wasn't taking any chances.

She asked her doctor's staff to contact Anthem and confirm that the treatment would be covered. They were told that, yes, this approach for this particular condition was acceptable to the insurer's bean counters.

Just to make sure, Barton said, she called Anthem herself. She wanted to hear it firsthand: Was the treatment covered by her family's insurance policy, for which they paid more than $1,000 a month in premiums, co-pays and deductibles?

No problem, Barton said an Anthem rep told her. You're covered.

So Barton's son made three trips to Children's Hospital of Orange County.

And guess what? Barton ended up fighting with Anthem over a treatment that the insurer now says was "investigative" or "not medically necessary" and thus not covered.

No, wait. Anthem did cover the third of the boy's three hospital visits. It rejected the first two, even though each visit involved the exact same procedure.

Even more perplexing, Barton said the company conceded that its customer reps made a mistake in saying that the treatment was approved -- not once but twice -- but it nevertheless denied her appeal and demanded that it be paid in full for the two outstanding treatments.

The bill: about $1,600.

Anthem told Barton that it wouldn't go after her. Instead, it went after the hospital.

The hospital, in turn, sent Barton a bill for the full cost of the treatment, leaving her vulnerable to a hit on her credit score if she didn't come up with some cash.

However, the hospital said this week -- after I took an interest in the matter -- that it would suspend its demand for payment until it could look into the case a bit more.

Remember, all this time and effort on Barton's and the hospital's part were required solely because Anthem, the insurer, erred in saying a procedure was covered when it seemingly wasn't.

"It's just unbelievable that they admit their employees made a mistake, but there's no accountability," Barton said. "I can't think of any other business where a company can be in error but still make others pay for their mistake."

Peggy Hinz, an Anthem spokeswoman, said the company remembers things a bit differently.

She acknowledged that Barton contacted the insurer last October seeking confirmation that the biofeedback treatment was covered.

But Hinz said Anthem's records indicate that Barton didn't have the necessary procedure code and said she'd have her son's doctor call back with the information. "There is no record that the provider called back with the codes for the biofeedback procedure," Hinz said.

Barton maintained in her letters to Anthem and in a complaint filed with the California Department of Managed Healthcare that she asked for and received confirmation that the procedure was approved.

In any case, Hinz said that Barton's doctor and Barton should have been told by the company that the jury's still out on biofeedback for chronic constipation.

"The conclusion from recent systematic reviews of biofeedback treatment for this problem is that there is not sufficient evidence from controlled trials to evaluate whether biofeedback treatments are helpful, nor which aspects of biofeedback are the most helpful and which patients are the most likely to be helped by biofeedback," she said.

However, a study published in the journal Clinical Gastroenterology and Hepatology in 2007 concluded that biofeedback was more effective than laxatives, diet or exercise.

"On the basis of our results, biofeedback therapy is the preferred treatment for patients with chronic constipation . . . and especially for those who have failed standard therapy," the authors of the study concluded.

Hinz was unable to explain why Anthem covered one of the three treatments received by Barton's son but not the other two. She said only that expenses related to the one hospital visit "were inadvertently paid without medical review."

But "in the interest of member satisfaction," Hinz said, the two other hospital visits "have been approved for payment administratively."

In other words, Anthem will at last make good on its promised coverage, despite having denied Barton's claim in February and then having rejected her appeal in April.

The hospital, it appears, is now also off the hook.

Amazing what a little sunshine will do.

One take-away from all of this is the importance of carefully documenting all communications with an insurance company. Get the full names of everyone you speak with -- and if a customer service rep refuses to give his or her name, immediately ask for a supervisor. Keep careful notes of all conversations, including the date and the time of the call.

Barton, for example, wrote down only that she spoke with a "Gustavo" and an "Alfredo." You need to do better than that.

And what about Barton's son? Turns out the biofeedback worked -- just as the scientists, if not Anthem, said it would.

"He didn't respond immediately," Barton said. "But over time, he's gotten better."

A poll this week found that a majority of Americans now believe that a public insurance option would help keep private insurers honest.

Can't imagine why.


David Lazarus' column runs Wednesdays and Sundays. Send your tips or feedback to

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