When Copay Saved The Day

, , , , , , , | Legal | November 6, 2019

(This takes place after I receive a statement from my medical insurance company, who is also my provider.)

Agent #1: “Thank you for calling [Company]. My name is [Agent #1]. May I please have your name and insurance number?”

Me: “Hello, my name is [My Name], and my number is [number].”

Agent #1: “How may I help you, Mr. [My Name]?”

Me: “I am calling about the statement that I received in the mail recently. There are several charges against my insurance that I don’t recognize. Those are the charges from [dates], for [amounts].”

Agent #1: “So, you are claiming that you did not make these charges?”

Me: “Yes, those are not my charges, and no one else has my insurance information.” 

Agent #1: *suddenly defensive* “So, are you saying that someone here at [Company] ran charges against your insurance? Could it be more likely that you gave your insurance card to someone else, and now you are trying to rip us off? I don’t know what you did, but we are not responsible for what you do, and we aren’t going to help you defraud us!”

(My insurance is very good; my copay is never more than $20 for Schedule 2 drugs and surgical procedures. Regardless, the accusation infuriates me more than the insurance fraud.)

Me: *furious, but keeping my temper in check* “Now you can transfer me to your manager.” 

Agent #1: “Why? So you can lie to her, as well? I’m not going to let you try to rip off [Company] anymore. Don’t call back or I’ll give your number to the federal government for insurance fraud!” *hangs up*

(By this point, I am absolutely furious and am about ready to call National Insurance Crime Bureau myself, but I decide to try one more time.)

Agent #2: “Hello, thank you for calling [Company]. May I have your name and insurance information?”

Me: “My name is [My Name] and my number is [number].”

Agent #2: “How may I help you today?”

Me: “Does the word HIPAA mean anything to you?”

Agent #2: *slightly confused* “Yes, of course. Every medical company follows HIPAA rules.”

Me: “Apparently not.” *explains situation* “Now, the first agent accused me outright of giving my insurance to someone else. I, however, have to wonder how your company gave my private medical information to some random person. That is a major HIPAA violation.”

Agent #2: “If you’ll hold for a moment, my manager wants to speak with you about this.”

Manager: *taking the line* “Hello, my name is [Manager], and I understand you have some issues with some charges against your insurance?”

Me: “No, I have issues with what your company has done, by the admission of your own agent and the charges I see here. There are charges on my account that I didn’t make. Now, one of two things happened here. One, someone else was allowed to use my insurance information to schedule an appointment, see a doctor, and get several high-class prescriptions, all without checking to see if they were me. That would be so many HIPAA violations I can’t even count them all. Or two, someone in your company is scamming insurance for money or drugs. That would be insurance fraud, in which case I would be within my rights to sue.”

(The manager is suddenly quiet, followed by the sounds of typing. When she comes back on the line, she sounds a little shaky and nervous.)

Manager: “If you’ll just bear with me for a little bit longer, I think I might know exactly what happened. Can you please confirm the dates, doctor’s name, and pharmacist name listed on your account?” 

Me: “The dates are [dates], all of them are listed as being with [Doctor], and the prescriptions are all listed as filled by [Pharmacist].”

Manager: *eerily calm now* “I think I have found the problem. Please give me a phone number, and I will call you back as soon as I get what I need.” *gives my number* “Again, my name is [Manager] and my direct extension is [number].” *call disconnects*

(She called me back about three hours later and explained everything. It seems that it was, in fact, insurance fraud: hundreds of thousands of dollars worth of it. From what the manager told me, the doctor, the pharmacist, and [Agent #1] were all family. It seems that they had been running a MASSIVE insurance scam, one where the doctor ran up fake appointments against insurance, usually avoiding triggering patient copay by billing it as a copay-free appointment. He would then write prescriptions, also against insurance, which would then be filled by the pharmacist, also his sister. They would then take those prescriptions and sell them for a much lower price and pocket the money. [Agent #1]’s job, it seems, was to direct patients away from any suspicion. Usually, he succeeded by claiming it was some type of hidden fee, but that insurance would handle it and there would be no charges for the patient. They messed up this time, though; my insurance is through the state, and one of the prescriptions that the doctor wrote automatically triggered the copay on the state insurance plan, thus my problem. This manager just happened to notice the family connection, and, when she opened the records, she put it all together from the appointment records. Things dragged on for a while, and the doctor tried to run once the feds started investigating, but in the end, all three were arrested. Last I heard, they are all facing very, very long sentences. As for the charges? They were reversed with no difficulty by the manager who took my call the first time.)

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Wrong Type Of Insurance

, , | Right | November 1, 2019

(One of our clients has home damage and is filing a claim. He hands in the damage report personally at the office. My colleague scans it and puts it through to the corresponding department. My coworker picks up the claim and the report. He flips through the report and his eyes grow.)

Coworker: “Is… is this the right file?”

Me: “How come?”

Coworker: “This is an autopsy report!”

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Nieces Happen

, , , | Right | October 28, 2019

(I am filing a warranty claim for my Xbox controller. I am filling out the online form and everything goes normally until I get to the part that asks how it was damaged. I hesitate a moment, considering how to explain the problem since I don’t actually know WHAT happened; it worked the day before, and then when I went to use it today it didn’t. This is what I put in:)

Form: “Eight-year-old niece. She probably dropped it, or pressed the button too hard repeatedly. Perhaps both, knowing her.”

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There Can Be Only One… Person To Help Me

, , , , | Right | October 20, 2019

(I work in an insurance office as an office staff member, meaning I don’t sell policies, but I service them. My coworker has been with the office for many years and knows our customers well. A customer walks in and approaches my desk:)

Customer: “Hi, is [Coworker] in?”

Me: “Yes, but she’s at lunch right now. I would be happy to help you, though.”

Customer: “No, thanks. [Coworker] called me earlier, and I’ve been working with her for years! She sold me my original policy, you know!”

Me: “That’s great! We love our long-term customers! She’s probably going to be out for twenty minutes or so. Do you want me to leave her a message, or perhaps I could look up something for you?”

Customer: “Oh, no. I’ll just wait for her.”

Me: “Are you sure? I’d feel bad for keeping you.”

Customer: “It’s no problem.”

Me: “All righty. Can I get you water or coffee while you wait?”

Customer: “Oh, no, thanks. I’ll just play with my phone a bit.”

Me: “Can I get your name, then, so I can have your file ready for [Coworker] when she gets back?”

Customer: “Oh, no, she’ll know who I am.”

Me: “I’m sure she will, but if I can grab your file, she’ll be able to get right to you.”

(The customer waves me off and sits in the lobby, playing with his phone. Approximately every five minutes, he grumbles about having to wait, and ponders why we’re given such long lunch breaks when we’re supposed to be working. Each time, I politely inform him that [Coworker] will return, and ask him if he’s sure I can’t help him. After approximately twenty minutes, [Coworker] does, indeed, return.)

Coworker: “Hey, [Customer]! How are you?”

Customer: “It’s about time you got back! I have been sitting here this whole time!”

Coworker: “Well, you know, I had to run some errands! What can I do for you?”

Customer: “Well, you called me this morning, and I didn’t understand the message!”

Coworker: *confused* “I haven’t called you today. Are you sure it wasn’t [My Name]?”

Customer: “It couldn’t have been her.”

Coworker: *to me* “Did you call [Customer’s Full Name]?”

Me: “Yes, I did. I wanted to let him know his payment had gone through, as he requested yesterday.”

Customer: “That’s not right! I’ve never spoken to you in my life! I only speak to [Coworker]!”

Me: “I’m sorry. I spoke to [Customer’s Full Name] yesterday, who requested I keep an eye on his automatic payment, as he had just updated his credit card info online, and I called to confirm it was posted to a card ending in [digits]. Was that not you?”

Customer: “That was me, but I never talked to you! I talked to [Coworker]! I never talk to anyone else, ever!”

Coworker: *reviewing our interaction notes* “I’m sorry, [Customer], but I haven’t spoken to you since last year. You’ve worked with [My Name] five times over the past several months.”

Customer: “Well, this isn’t right. I shouldn’t be tricked like this! I expect to talk to [Coworker] every time!”

Coworker: “I’m sorry, but sometimes I’m not available. [My Name] is just as licensed and knows what I do.”

Customer: “What am I paying for if I don’t get to talk to [Coworker]? This is ridiculous!”

Coworker: “You are paying for an insurance product. We are the staff that advises and guides you. Everyone in this office is licensed by the state and bonded by the company to help you.”

Customer: “This is ridiculous. You’ve been lying to me all year. I wait all day to talk to you, and you tell me I can’t even talk to you. SHE—” *pointing to me* “—can’t even help me!”

([Coworker] started to explain, again, that she is not always available, but [Customer] had had enough, and left with a slam of the door. He later called to cancel all of his policies, but never completed the process. Sadly, this was a pretty common occurrence in our small town.)

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His Reason To Be Angry Has Been Cancelled

, , , | Right | October 10, 2019

(I work in a call center for a government agency that helps people pay for their health insurance plans. It’s not uncommon for people to be confused about how to cancel insurance, to make mistakes, and to blame us when they make those mistakes, so I dread whenever someone calls and says they have an issue with a cancellation.)

Me: “Hello! Thank you for calling [Government Agency]! What can I do to assist you today?”

Caller: “I’m still being charged for insurance I cancelled four months ago! I’m getting really angry now and I want you to stop billing me!”

Me: “I’m so sorry to hear that, sir. We are not the insurance company, so we aren’t involved with sending you bills, but I’m happy to do whatever I can do to help you!”

(I ask for his information and find his account.)

Me: “Oh, well, I don’t see that you called to cancel your insurance plan and it’s still active. When did you call us to cancel?”

Caller: “D*** it, are you calling me a liar?! I cancelled my plan and I want you to stop f****** billing me!”

Me: “I understand you’re frustrated, sir, but I am trying to help you. Do you remember approximately when you called us to cancel? Or did you maybe call the insurance company?”

(At this point, I’m thinking he accidentally called the insurance company to cancel, because that’s a common mistake. When someone’s insurance is partially financed through our agency, they can only cancel by calling us directly.)

Caller: “I didn’t call anyone, d*** it! I did what anyone does to cancel a service! I wrote ‘cancel’ on the bill’s envelope and had it mailed back return-to-sender!”

(Well, that’s a new one. I try very patiently to explain that that is not a valid method of making a cancellation and that those automated billing statements from insurance companies aren’t sent from an address where people can receive mail. I also gently explain that even if the insurance company had gotten the letter, they couldn’t have done anything with it. To cancel, a person needs to either call us directly and validate their identity or to go online and cancel using their password-protected account. This goes on for twenty-five minutes.)

Me: “Again, I do understand that you feel frustrated with this situation, sir, but that was not an accepted method of cancelling. I can cancel your insurance moving forward, but you will still be responsible for the past month’s premiums.”

Caller: “How stupid can you be?! This is how I’ve always cancelled things in the past! I don’t owe anything! Did you even graduate high school?! Give me someone with a brain! I want a supervisor!”

(I seriously doubt most places would accept what he did as a valid cancellation, but I apologized once again for his frustration and connected him with a supervisor who told him the exact same thing. He called back four times that day, trying to find someone who could give him a different answer.)

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