Health Insurance Isn’t Supposed to Work Like This

There are lots of reasons you may have heard of Zoë Keating. She’s a prolific musician, turning her single cello into a thick, vibrant orchestra of sounds. She’s a social activist, lending her voice to causes such as Save the Post Office.

She’s also unafraid to write about money, and became the public face behind musician streaming revenue when she released her streaming revenue from Spotify, Pandora, and other sites online in a series of Google Docs. (The Atlantic helpfully summarized her data, if you like looking at charts.)

Last week, the internet learned about Zoë Keating in another, sadder way. Her husband, Jeffrey Rusch, has cancer, and Anthem Blue Cross sent the family a letter informing them that the health insurance company would not pay for any of his treatments.

Keating quotes from the letter on her Tumblr:

Our Medical Reviewer Layma Jarjour MD has determined we cannot approve your hospital stay for cancer. We do not have enough facts to show that it was medically necessary.

This came after Rusch’s primary care doctor ordered him to go to the hospital right away, after more than a pint of fluid was removed from his lungs, and after Rusch underwent a round of emergency chemotherapy.

This isn’t how the ACA is supposed to work. It isn’t how health insurance is supposed to work. As Keating noted, she and her family have paid more than $100,000 in premiums to Anthem Blue Cross since 2008. If you pay into the system, the system is supposed to take care of you.

Fans of Keating’s music quickly started sharing the story, filling Twitter feeds and Tumblr reblogs with links. The San Francisco CBS affiliate picked up the story and ran a piece titled Sonoma County Man Battling Cancer Denied Coverage By Anthem Blue Cross After Paying $100K In Premiums.

Then Keating got a call from an Anthem representative.

The call, which she has transcribed on her Tumblr, essentially states that when Anthem receives potential claims, it confirms with the hospital that those claims are medically necessary. Rusch’s hospital was slow on responding to Anthem, and when the system did not receive a response, it spit out the “not medically necessary” letter that Keating received. It was an error of automation, in many ways.

Rusch’s stay will be covered by his insurer. And we now all know a little bit more about how the health care system works.

 

Photo: George Kelly

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14 Comments / Post A Comment

Kthompson (#1,858)

When I worked at Evil Dental Insurance Company, we used any reason to deny a claim. “Well the signature here isn’t really on the line. Denied.” “It took their office more than week to send that invoice. Denied.” “They forgot to check this box right here. Denied.” It was really sickening.

Trilby (#191)

It’s never smart to get yourself in an uproar without first talking to someone. These huge bureaucracies mess up. A lot! And it takes patience to straighten things out but it can be done. Should this happen? of course not, never! Yet it does, and must be dealt with reasonably so as not to give yourself a stroke. This story is a prime example of the myriad human-error-type things that do go wrong and can get fixed.

eatmoredumplings (#3,808)

@Trilby Maybe, but the letter they got apparently didn’t say “call to talk to someone,” it said “you can file a grievance,” which sounds like a much more formal procedure with a low likelihood of success. Cold-calling your insurance company and trying to get someone on the phone who actually can comment on the details of your case is not always successful; I don’t know if she would’ve gotten the detailed explanation she got from the representative without making such an uproar that the company actually paid attention. (I’m having tough times with my insurance lately, if you can’t tell….)

E$ (#1,636)

@eatmoredumplings @Trilby Also, the denial letter didn’t say “We couldn’t approve this because we didn’t get the right paperwork from the hospital” or “Because bureaucracy,” it said “not medically necessary.”

A friend of mine lost a baby last year (a really hard, sad, terrible thing) and her insurance company is still sending paperwork in that baby’s name. Sure, it’s just an accident or a policy, but it’s also immensely hurtful. Part of customer service in health care is recognizing that these are sensitive issues. Sending a “not medically necessary” letter to the spouse of a sick man is really insensitive.

SnarlFurillo (#2,538)

@Trilby Anthem Blue Cross is notoriously evil though? I kind of assume it was not an error, just that ABC figures most people will not appeal except in the most egregious cases and in those cases they will shrug and say, “Paperwork error” before paying up.

Trilby (#191)

@E$ No it didn’t say those things. I guess I’ve had enough life experience that I know to ask, and how to ask, and to keep asking until I get reasonable answers. Really, try it. It saves a lot of anxiety.

Trilby (#191)

@SnarlFurillo Well, yes, I do sometimes think that their first reaction is to deny claims, hoping you’ll go away….. But if you have cancer, you have to be persistent. I know it sucks! I’m not saying it doesn’t. It’s just how it is. Learn the system.

@Trilby It is a system that is inherently unfair for people without time, resources, money to be persistent, or the education or literacy skills to navigate the system. The system is fucked and our response shouldn’t be, “That’s how it is!” Our response should be “How it is needs to change.”

@Trilby If you have cancer, I imagine you should be spending your energy fighting the cancer, not the insurance company that you’ve paid large sums of money to handle things like this.

jennonthego (#5,366)

@Trilby Although I likely would have called someone to complain, the fact that the letter states a particular doctor reviewed my claim and deemed it “not medically necessary” would have stopped me cold and infuriated me. To assign someone’s name (a doctor) to the denial gives it more weight than just “Anthem doesn’t want to pay for this.”

honey cowl (#1,510)

@Trilby I think there is a lot of privilege endemic to being willing and able to fight these kinds of battles with insurance companies. “Learn the system” only works for a certain class of privileged people, and I think it’s important to recognize that.

Sloane (#675)

@honey cowl There is also a lot of privilege in the activity of blogging grievances on Tumblr. Mayhap even the same privilege that would enable the blogger to make a phone call and learn the system.

honey cowl (#1,510)

@Sloane For sure! I totally agree with you. I guess I was thinking that, beyond this specific case, saying “Learn the system!” isn’t a satisfactory response. And as @avianbonesyndrome said, it’s often much easier for a patient or caretaker to vent than it is to navigate a phone tree. YMMV.

HelloTheFuture (#5,275)

Zoe Keating has another update on her Tumblr. Turns out “we’re paying for treatment” may not mean “were paying for treatment.” http://zoekeating.tumblr.com/post/87816026799/read-the-fine-print

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