Frustrated in Shoreham

I am frustrated about the health insurance issues in Vermont. Lately, I have heard how wonderful Blue Cross/Blue Shield is and how wonderful the Catamount Insurance program is for Vermonters. I have a very different opinion. For ten or more years I have been self-insured through Blue Cross/Blue Shield of Vermont. I became an individual payer with them when the Golden Rule Company ceased insuring Vermonters. The Golden Rule customers were put out for bid and Blue Cross/Blue Shield won the bid. At that time BC/BS was much more expensive than Golden Rule. Part of their agreement in order to acquire the Golden Rule customers was that they were limited to a certain percentage raise in their rates per year until they brought the Golden Rule customers up to par with the BC/BS rates. Each year my health insurance has gone up. The notice comes in January that the rate will increase for the March payment. This year my $1,000 deductible policy was going up $100 per month, making it $399 per month for my own personal insurance. (My job does not provide insurance benefits.) Knowing I could not pay that rate, I checked with them to see if I could raise my deductible and lower the rate. I was told I could raise the rate and was given various options. I chose to raise my major medical deductible to $5,000, keeping the prescription deductible at $100 per year. I sent in the appropriate forms on time. When I received the bill for March 2008, I was surprised to see that my payment was $399. The change had not been made. Now the phone calls started. I called Blue Cross/Blue Shield to inquire why I was being billed at the higher rate. I was informed that though my paperwork was in their possession, they had not processed it yet and therefore I would have to pay the $399 instead of $299. But, they assured me that the change would be made by the next month. I asked, "What happens if I can't pay the $399 for March?" The response was that my policy would be canceled. I expressed my displeasure and asked to speak with a supervisor. I was put on hold for a long time, and I thought, disconnected. I called back and got a less helpful person who said she would need to check with a supervisor who wasn't available, and that I should send in the check for the higher amount. I decided to call the Vermont Banking and Insurance commission to voice a complaint. I called the Banking and Insurance Commission. The person I needed to speak with was not in so I left a voice message regarding the situation. Meanwhile the Blue Cross/Blue Shield supervisor calls back and I get to tell her I have called the Banking and Insurance Commission. She was immediately helpful and told me there would be no problem. I could pay the reduced rate and they would deal with the paperwork. Shortly after that a very concerned person called from the Banking and Insurance Commission. I was able to tell her the problem had been solved and she replied that if I had any further problems I should not hesitate to call. Now fast forward one month to April 2009. I go to the doc for a physical. He is not a Blue Cross Blue Shield provider. Too much paperwork to file the claims. Okay. I am not sick a lot and I can pay the $100 for the office call plus the tests, I guess. (If I go to a BCBS participating provider I pay a $15 co-pay) I'll file the claim and the cost of the visit should go towards my $5,000 deductible. This I do. Fast forward another month to the end of June. The claim is sent back to doc's office because I put the group number where the personal I.D. number should have gone and vice versa. The office staff calls me and I go down to pick up the forms. I make the correction and send it back to Blue Cross Blue Shield claims department. Fast forward to the July. The claim comes back to me because one number in my I.D. has an extra numeral in it. I correct it and return it to Blue Cross/Blue Shield. Fast Forward a couple weeks. The claim comes back because the doctor had not cited a diagnosis for the office visit and tests. I call BC/BS again. They tell me they cannot apply the amount towards my deductible until they have the diagnosis in writing from the doctor. They ask me for what reason did I visit the doctor. I tell the it was a routine physical to check for cholesterol, diabetes, heart disease, thyroid levels etc. I am told to get something in writing from the doctor's office. The next day I drive to doc's office again. I have the forms which should have earned frequent flyer miles by now and a stamped envelope addressed to Blue Cross Blue Shield. I make my request that they write a note to Blue Cross Blue Shield to verify my reason for visiting the physician. I am assured that this will happen and I leave the forms and stamped envelop with them. Fast forward to Aug. 25 at approximately 6 p.m. The telephone rings and, guess who? That's right, it is my old friends at Blue Cross Blue Shield. A young woman's voice informs me that I have not complied with their request for the proper information from the doctor and my claim is being denied and closed. This now starts a long conversation about why I raised my deductible, why I don't have a doctor that is a participating provider, how I have complied with all their requests and why I don't qualify for the Catamount Healthcare program. This really didn't get me anywhere so I asked to speak with someone from the claims department. The woman tells me that the claims department does not accept calls. I am not to be deterred. It is now 6:15 and I tell her that I need to speak with a supervisor or I am going to call my acquaintances at the Vermont Banking and Insurance Commission again to see if we can get this straightened out. When the supervisor comes on the phone, she seems very pleasant and reasonable (oh I forgot to tell you that the calls are all recorded for quality assurance). Now the supervisor tells me that I could have just told them over the phone last month what the doctor's visit was for. I ask: "Why didn't someone tell me that instead of having me drive to the doctor ask the for a letter?" So I tell her right then and there what the office call and tests were for and that I seem to have no major health issues at this time. The nice supervisor says that they will still need verification from the doctor but it can be faxed and she gives me the claim number, her fax number and her first name. She says that as soon as they receive the fax from the doctor, she will call and let me know it is there. The next day is Aug. 26. I drive the three miles to the doctor's office. They are closed for two days. As of this writing I have not been successful in getting this resolved. I do have to go to work and don't spend all my time thinking about Blue Cross and Blue Shield. Tomorrow I'll call the doc's office form work and give them the claim number, the woman's name and the fax number and hope they send satisfactory information in a timely manner. If you have become weary just reading this ridiculous account, then think how I feel. I am a reasonably healthy person who can take the time to deal with this but why should I have to? I don't believe in socialized medicine. I don't mind paying for insurance if I can use it. I believe doctors deserve to be paid well. I don't really want to have my health care paid for by other taxpayers. I just want to be able to file this *#&%$ claim and receive the services for which I have paid. Susan B. Peden Shoreham, Vt.

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