Steps to take when disputing denied health insurance claim

The Journey

Most people heading into retirement know life after work isn’t all shuffleboard on the lido deck.

There can be serious money and health care concerns, not to mention worries about boredom and relationship conflict with all that newfound free time.

Less apparent may be the sheer number of hours some retirees put in to straighten out the complications that can crop up when managing life in retirement.

Larry Tocco enrolled in Medicare after he retired last year from a job in the collections department of a credit union in Virginia.

After a couple of medical procedures this year, he began getting past-due notices in March from health care providers after his claims on a Medicare Advantage plan weren’t paid.

A frustrating round of phone calls later, he learned he was still on the active employee rolls with Anthem HealthKeepers, the health insurance plan covering his former employer, and so his Medicare Advantage plan was being considered secondary coverage.

A benefits manager from the credit union told him the company had sent notification about his retirement, but Anthem representatives said they didn’t get the notice. More than two months later, the issue was still unresolved, and Tocco said he was told he was still on the insurance rolls at Anthem, despite being enrolled in a Medicare Advantage plan with another carrier.

“I’m at my wit’s end,” the 66-year-old wrote in a letter to this column. In a follow-up interview, he said the total amount of the bills was less than $400. His larger worry, he said, was what could happen if he suddenly had a major health issue before this is resolved and couldn’t advocate for himself.

Having worked in collections, Tocco also understood keenly that if the past-due bills ended up going to a collection agency, his personal credit rating could be dinged.

Along the way, Tocco has kept careful notes of conversations with Anthem, the credit union and his current Medicare Advantage Plan provider, UnitedHealthcare.

That’s hugely important for getting to a quicker resolution on customer service and billing issues, said Charna Posin, a senior advocate with Senior Concerns, a Thousand Oaks, Calif., nonprofit organization that provides adult day care and other services, including pro bono legal work.

Documentation isn’t always enough, however, as Posin learned firsthand when, she said, she spent nearly two years battling to have anesthesia services covered after she shattered an elbow. Her surgeon was considered in-network on her insurance plan, but the anesthesiologist was not, and it took many months to prove that the surgeon, not Posin, chose the anesthesiologist and therefore she shouldn’t have been stuck with the charge.

“When entities won’t talk to each other, you’re just in a loop,” said Posin, who went for training to become a patient advocate after the experience.

Even so, patients are much better off in the complaint process if they have documentation, she said, so she counsels seniors to keep a calendar diary anytime a benefits, health insurance or contractor dispute issue arises.

“Write down the name, title and phone number of the person you speak with and what was said. Otherwise you’re just a red-inthe-face senior, and no one’s going to listen. You won’t be respected if you’re hysterical,” she said.

Another tip for breaking through a loop: Enlist a third party.

“If you get a claim denial, always contact your doctor or hospital to see if they can help you through the appeal,” said Shirley Whitenack, president of the National Academy of Elder Law Attorneys and a partner with law firm Schenck, Price, Smith & King.

You can also file a complaint with your state insurance department or contact the Center for Medicare Advocacy ( medi careadvocacy.org), which offers self-help packets for several types of claim denials. Another avenue is the Medicare program itself, the Centers for Medicare & Medicaid Services. The department’s Benefits Coordination & Recovery Center operates a customer service line Monday through Friday from 8 a.m. to 8 p.m. at 855-7982627.

“I can tell you this scenario is not foreign to me,” the Center for Medicare Advocacy’s executive director, Judith Stein, wrote in an email. “All sorts of unexpected glitches can lead people to not being (properly) enrolled in Medicare.”

After inquiries from this column, Anthem spokesman Scott Golden said the issue has been straightened out, and Tocco has been removed from coverage.

“I never thought this was how I’d be spending my time” in retirement, Tocco said.

Patients are much better off in the complaint process if they have documentation.

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