Fighting with insurance, part 1

Let’s get started.

Hey there–

I want to introduce you to Barbara Faubion. For 25 years, she worked for an insurance broker. Whenever one of his clients had a problem with their insurance, Barbara got it fixed. 

As we’ve talked about so many times in this newsletter, there are a lot of problems with insurance.

Insurance companies deny all kinds of claims for all kinds of reasons, some of them nonsense, some of them shockingly horrible in the bad faith they seem to exude. Sometimes they don’t even read the claims. The number of denials seems to be going up, and the reasons seem to be getting weirder.  

And of course, once they’ve made a denial, it’s easier for them to stand pat than for you to change their minds.

But it’s not hopeless. I’ve talked with folks who know how to fight and win. Some of them have done it for a living, for decades. Barbara’s one of them. 

“If you had a claim and you had a problem, you called Barbara, and Barbara took care of it,” she told me. “That’s who I was. And I loved it.”

I’m not saying that you’ll love it — for one thing, Barbara was getting paid to do this, which sweetened the deal.  

And when she didn’t win (not every case was winnable) it didn’t cost her money. 

We don’t get those advantages. But we can learn from Barbara. Here are some of her top tips, from when I talked with her for An Arm and a Leg in 2020.

Before you start

Set aside the time. Maybe bring snacks.

This is one of the hardest bits of advice to follow — not the snacks, but the time — and it’s where Barbara had an unfair advantage: When she fought insurance claims, she was on the clock. She wasn’t stealing time from her personal life, or her job.

But you can’t skip the time fighting for these claims. She told me she could spend four hours on the phone for a single case. 

And yep, that often meant multiple conversations with multiple people. “I’m saying, ‘OK let me talk to your supervisor…’” she told me. Again and again, and again. “You know, I’m just going up the ladder.”

So, yes, maybe bring snacks or a water bottle. And maybe review our tips about how to keep your cool through this kind of process, because it can get really infuriating. 

One extremely relevant piece of advice from that newsletter? Don’t try to get everything done in one phone call, especially for a complicated claim. It can be easier to break things down into smaller steps, with mini goals for each call.

Get organized. 

Before you pick up the phone, open up something to take notes on — paper or digital — and include a few things at the top of your notes about each call.

• The number you’re calling

• The date and time

• The name of the person you reach — whatever name they’ll give you

• A reference number for the call (Barbara says there’s always a reference number.)

Start asking questions. And keep asking.

This is Barbara’s big trick. “Just pick up the phone,” she said. “Call the company and ask why [what you’re being charged for] is not covered. And if you don’t like the answer, you ask, ‘Why? Explain it to me.’” 

I got the same advice from a woman who worked for a big insurance company: “Just tell them: ‘I’m sorry, I’m not understanding. Break it down for me.’”

And if you’re not getting answers that make sense, it may be time to ask for a supervisor. 

Know what kind of problem you’re dealing with

This is the point of your initial rounds of questions: figuring out which of three categories your problem falls into. We’ll start with the worst case.

Scenario 1: There’s no mistake, you’re just not covered as you should be

Unfortunately, insurance often sucks. There are things it just doesn’t cover. 

We end up on the hook for giant deductibles, and co-pays, and the dreaded co-insurance, and it can add up to a lot — thousands of dollars.

Barbara ran into this too. Sometimes all she could do was confirm the bad news, and explain it to whoever she was trying to help.

But a lot of the time, she said her investigations turned up different problems — ones that could be fixed.  

Scenario 2: The provider gave the “wrong” code.

When providers bill insurance, every charge comes with a code, usually called a CPT code. We’ve talked about these before, and we still owe you more depth. 

But what you should know for now is that, something a provider does usually can be described by more than one code. 

A solution: Find a different code for the same thing — one the insurance company will pay for.

For instance, this list of common codes for physical therapy includes “Therapeutic Exercise” (97110) and “Therapeutic Activities” (97530), not to mention three different codes for “Strapping.”

Barbara says the insurance company staff probably won’t tell you which codes are covered and which aren’t.

But if you dig up a few candidates on your own, they should answer yes/no questions: “Is code xyz covered?  How about code abcde?”

But getting the codes is only half the battle. Then, you’ll have to get your provider to submit a new bill, with the right codes. And get the insurer to OK it.

Which, Barbara said, can take months, all told.  

Ouch. I know. But: It’s a way forward.

Scenario 3: The insurer made a mistake.

They denied something that — under their own rules — they were supposed to approve. In this case, you can submit a written appeal. 

And although there’s a lot to know about crafting appeals (we’ll cover some of it soon) Barbara says to just ask direct questions about what to say.

“I don’t have any problem asking, ‘What do I need to do to appeal this?’” she told me. “And then they would tell me, ‘Well, it says in the policy that this is excluded’ or whatever.”

And then she kept asking: “‘So how do I get around that? How do I word it?’ And they would give me information.”

You should know: Barbara is very charming, and always made a point of being nice and friendly with whoever she talked with. 

Which, again: May have been a little easier because she was practicing her profession, on the clock, the whole time. But still, her attitude is worth keeping in mind.

Can HR help? 

Yep, sometimes. I met Barbara through an HR guy named Steve Benasso, who loved to help his colleagues fight off bogus bills and unfair insurance denials.

“I do it every month,” he told me when I talked with him for An Arm and a Leg. “I am a bulldog on this stuff.”

He learned everything he knew from Barbara, when his company used the insurance agency she worked for.

Of course, not everybody has a Steve Benasso as their HR guy. I wish.  

But I can pass on some bonus lessons — Steve’s own summary of what he learned from Barbara:

1. Trust yourself. “If you think something looks like it's incorrect, there's a good chance it is. Don't doubt yourself just because you got this very official-looking bill in the mail.”

2. Be brave. “You have to be willing to stand up for yourself. You have to be willing to tell people in authority sometimes, that you believe they're wrong.”

3. Expect a long haul. Keep going. “I tell people, you're going to get the answer ‘No’ at least three times.” Make the fourth call. 

Sound like a lot? It is.

You know we feel this way. But let us say it again.

It is not a bit reasonable to expect regular humans to fight through phone trees, talk to however-many people, ask for however-many supervisors, keep immaculate records, learn all about medical billing codes and gawd knows what else.

... all while holding down jobs, cooking our own food, and otherwise taking care of our families, friends and selves. 

And I’ll introduce one more voice from An Arm and a Leg: Kaetlyn, who fought an insurance company on her own behalf in the early days of COVID, when she was too sick to work and the landlord was beating down the door.

She had one obvious advantage: She worked at a financial institution’s call center, helping people who were behind on their bills. She knew how things worked behind the scenes.

But she acknowledged a second big advantage: She presented as a college-educated white woman – so she wasn’t facing some of the systemic disadvantages that other marginalized people have to take on in these settings. 

Kaetlyn summed up what that meant: “I've got a lot of things going for me that make people treat me nicely and that make people give me second chances. So I know that some of the things I'm saying [to try], it may not be so smooth and easy for other people. They may not get the level of slack that I do. But it's worth a shot.”

We know it’s hard, in a lot of different ways. But if some insurance company is saying you’re on the hook for hundreds or thousands of dollars, and you think they’re wrong, please: Take your shot. And don’t forget to take care of yourself along the way. 

Next time, we’ll get into the specifics of putting an insurance appeal in writing, guided by an insurance-industry veteran.

An ask: Help us put AI to work for you

We are planning an upcoming podcast episode about AI. And we could use your help.

We need raw material to help us answer a question: Can we train ChatGPT to make it easier to appeal stupid insurance denials?

If you’ve gotten a denial recently, and you’d like some help from a chatbot — and an actual human expert that we will recruit — please get in touch?

Let us know the story, and include the relevant documents. If we use your story we will want to talk with you, and maybe put your voice on the show. But we won’t share your personal information without your OK.

Are you game? Or, do you know somebody who might be? Let’s get our new robot overlords working for us, while we can.

And besides, I’m pretty sure the folks at the insurance companies are already trying to do the same. Let’s start catching up. 

Dan

Wanna listen up for more instructions, examples and pep talks?

• Our interview with Barbara Faubion: She tangled with health insurance every day for 25 years. And loved it. Here’s what she can teach us.

• Our talk with Barbara’s disciple, HR guy Steve Benasso: How to fight like a bulldog (against bogus medical bills and insurance denials)

• Our talk with an insurance-company veteran about how she tackles her own insurance problems:  From inside the health insurance company: Angst and advice

• And our talk with Kaetlyn about how she clawed her way back from the financial brink during early COVID, one phone call at a time.