Patient Advocacy: Winning the Battle Against Blue Cross Blue Shield

Posted by on Oct 24, 2014

As much as I don’t want to spend another minute on this topic, I think it’s necessary to talk about this last week and what has happened with Blue Cross Blue Shield.

Let’s put the happy ending of the story first: I won my battle with Blue Cross Blue Shield and was able to return to treatment as of last night.

I have learned two things from the experience of successfully going up against my insurance company on my own:

  1. It is possible to reverse an insurance company’s decision. They bank on most people giving up after the first few “no’s,” so you just have to make sure to push them far enough.
  2. Patients should never do their own advocacy.

As I wrote last week, my insurance company decided to cut off my IOP treatment. My treatment team appealed the decision, which was denied. They appealed again and were denied again.

The story picks up Monday. (The second denial conveniently happened at 4:55 on Friday, so by the time I called to protest, everyone at Blue Cross Blue Shield had left for the day.) I called my case manager and demanded to speak to her supervisor. The supervisor was moderately empathetic, but said there was nothing she could do. I had to speak with the grievances and appeals department instead.

Blue Cross Blue ShieldTuesday. I get a call from Dan, the senior behavior health appeal coordinator. He informed me that I could make a “second-level appeal,” which would be the final appeal before I had to go to New York State to settle the matter. To do this, I would need to write a letter detailing why I disagree with the denial, then send it directly to him.

In order to craft my own appeal, I needed to see the Blue Cross Blue Shield doctors’ notes explaining why they denied my case. This is the point that every patient should avoid, if possible. I knew I needed to see the notes in order to build my case, and I knew they would be difficult to read. I didn’t anticipate just how difficult. Everything was there in black and white. My history, my presenting issues, my interpersonal struggles — all of it stated with a shameful matter-of-factness. Even worse, the notes stated my weight, charting every pound lost or gained since I’d started treatment. The last time I’d seen my weight was February, when I first arrived at residential treatment. So, naturally, the current number was rather shocking.

I managed to write the letter, arguing that the majority of what the first doctor said was either exaggerated or blatantly false, and that the second doctor’s findings actually contradicted the first doctor’s, which made me wonder whether Blue Cross Blue Shield doctors use any standards at all. (And both of them, meanwhile, continued to reference my weight, even though weight is not a criterion for medical necessity at the IOP level of care.) I reminded Anthem/Blue Cross Blue Shield that I do, in fact, meet medical necessity criteria by Anthem Blue Cross Blue Shield’s standards, and thus denying me treatment would be a violation of federal parity and Timothy’s Law.

I sent the letter, and then tried to eat lunch. That was when the shock and horror of seeing my weight caught up with me. The emotions that flooded me were as strong as they were a year ago — fear, panic, desperation, powerlessness… an all-around sense of being out-of-control. I went through every coping skill I could think of. I emailed my nutritionist and therapist, I called my husband — I even considered going to Monte Nido to ask if I could have lunch there, for fear that I wouldn’t be able to do it alone.

In the end, with the help of my three primary supports, I ate lunch. It took two hours and it required me to break down the process into simple steps like “Stand up. Walk outside. Walk down the block. Go into the sandwich shop.” But I did it nonetheless. It terrified me to know that my eating disorder, when it awaked, was still as powerful as it was a year ago. Then again, a year ago I would have lost that battle.

Wednesday. Dan had promised that I would know the outcome of the second-level appeal by noon. At 2:00, I received an email saying that the denial has been upheld, and at this point I would have to take my appeal to the State of New York. Even worse, the third doctor’s explanations for denial were no different than the last doctor’s explanations. Had they even read my letter striking down those explanations?

I was furious. I called Dan immediately and told him that he needed to break down the decision for me point by point and explain exactly why I did not meet medical criteria, when according to Anthem/Blue Cross Blue Shield policy, I did. He told me that he didn’t know — he was at the head of the process, but he didn’t have any role in the decision-making. I asked, “So who can explain this to me?” He gave me the name of Anthem’s medical director Steven Korn and said he would have him call me.

I was feeling desperate. It seemed like I had nothing to lose. So I sent an email to Dr. Steven Korn, and CC’d someone from the Attorney General’s office (it was a random email I found on their website), someone from the Community Service Society of New York (I actually have no idea who they are — but they do health advocacy, and I needed this email to be flashy), and Dan.

I wrote:

Dear Dr. Korn,

I received your name from Daniel Huben at Anthem. Mr. Huben says you are the one who can explain to me why the doctors consulted by Blue Cross Blue Shield have gone against my treatment team’s recommendations for further treatment for anorexia nervosa at the intensive outpatient (IOP) level of care at Monte Nido’s Eating Disorder Treatment of New York. These doctors have made these denials of treatment despite the fact that I meet medical necessity criteria as laid out by Blue Cross Blue Shield (see “severity of illness” criteria for IOP treatment in Anthem’s Behavioral Health Medical Necessity Criteria).

It is noted in my charts that my treatment team requested six additional treatment days, which would have allowed time to begin discharge planning, such as finding outpatients groups to admit to. By denying me this relatively short amount of time, Anthem Blue Cross Blue Shield has left me only with twice weekly therapy, thus putting me at risk of regressing without these IOP services. Cutting me off suddenly from treatment is at best careless, and at worst negligent on the parts of Anthem’s Drs. Daniel Harrop, Thomas Krajewski, Christine Adams, and yourself.

I look forward to hearing from you soon so that I may move forward in a timely manner with my treatment. I expect that, as a consumer of your service with very clear legal rights, as stated by federal parity laws and Timothy’s Law in New York State, I will be able to receive the treatment I am entitled to.

Within an hour, I received a call from Dr. Korn. To my surprise, he was rather cordial and patient. He listened as I told him how I had been cut off without any notice, why I needed the transition, and how much I had been struggling this week without my treatment team.

He chuckled a bit and said, “You are the most persistent client I’ve ever seen. I’ve never seen someone work this hard.” Then, he finally asked the question that should have been asked of me last Thursday by my case manager: “What do you need?”

“I need to go back to treatment,” I said.

He said all right, he would reverse the decisions and get me a few more weeks at Monte Nido. I immediately burst into tears and thanked him profusely, not caring what I must have sounded like at that moment.

And just like that, I was back in treatment the very next night.

I write this to convey to all you that it IS possible to advocate for yourself in the fight again an insurance company. This is something I learned from the Eating Disorder Coalition, especially Kathleen MacDonald. At Lobby Day on October 1, Kathleen told us that advocacy is, “passion, sacrifice, determination, change-making, hope, authentic. It’s personal.” That is what stuck with me throughout this last week: It’s personal. The reason I was able to push ahead despite “no,” after “no,” after “no” was because this was my health and my life at stake. Moreover, I had learned on Lobby Day that I CAN make people listen to me and that what I say DOES make a difference.

So yes, it is possible to advocate for yourself; however, just based on my personal experience this last week, I would advise you do so only if you have run out of other options. Ideally, your treatment team, your family, a lawyer, or some other representative can deal with the insurance company for you, because the most important thing for you to do is concentrate on recovery. Getting bogged down in your own medical charts and spending hours ardently convincing an indifferent person that you are, in fact, sick does not help your recovery in the least.

Whatever you do though — whether you can add your voice to your team’s advocacy efforts or you need to go up against your insurance company on your own — I offer this takeaway: Nothing is impossible.

So don’t ever give up. Ever.


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11 Comments

  1. Thank you for sharing this. I recently had a run in with Dr Harrop and urge everyone to find advocacy early and to follow all your advice. thank you.

  2. I have been fighting with Blue Shield 65 plus for 2 years. I initially received an authorization for a reclast injection and was told my co-pay would be $100.00, When I received a bill from Curascript it was for 1,105.51. The billing had a column for date of service, rx description, Authorization, amt. billed ins. and Due immediately from patient. All columns were blank except 1105.51 due immediately. I called Curascript and was told that the claim was denied by Blue Shield but would summit it again.When I continued to receive bills I called Blue Shield and was told they would research it and call me after researching it. After not hearing from anyone I called again and was told the same thing .I continued to call and was told not to worry they would straighten it out and call me back. When I continued to call I would ask for the person I talked to before but was told I had to talk to the person who answered the call. I have name after name of persons I talked to but no last names because they are not allowed to give it out. No one ever called me back with any information . At one time I was put on hold by Fernando and said he had opened a claim and someone assigned to the case would be contacting me, no one ever did. When I called again I was told by a Claudia that the billing was correct because I had a procedure done with no authorization ant the complete charges for the 30 minute procedure was 4462.00 and the 1105.52 was my co-pay This was the first time I was told this. I asked for a copy of everything pertaining to these charges .Also at this time I was told there was not a claim on file because it had to be in writing. I wrote a detailed letter more detailed than what I am writing here. I received a letter telling me that it was beyond the time allowed for an appeal, It also said I did not give enough information which was on the letter I wrote. I resent copies of the Authorization and today I received a letter of denial due to not appealing within the allotted time. On the denial letter It stated that I have the right to request all copies of documents and records relevant to my appeal I have requested this but to this date I have not received anything telling me why it was denied in the first place. can anyone advise me what I can do now? This has been nothing but going around it circles.

  3. Thank you all for sharing your stories. There are probably many many, more people, who have not yet shared theirs. There are some key points that are worth emphasizing:
    1. Persistence is required
    2 Getting to the person who has a clinical background and is a decision-maker is VERY important (the rest of the folks are buried in “clerk-mentality”, which is not better than that of “used care salesman”
    2. “This has been nothing but going around it circles”- that is the expected effect of the entire game being played by companies (Insurance and pharmacy-benefits)
    3. WRITE/email rather than call.
    4. “CC” to someone who is a BIG FISH (your employer, the state, a congress person, etc.)- unfortunately, that’s what it will take to get noticed
    5. This is a scenario of having to “make me do it”- I think you know what I mean.

  4. One last point, helps to have your doctor has to be on your side, as your advocate too. They know what technical lingo to put into the paperwork that goes to the insurance company 😉

  5. Thank you for sharing! Ran across your blog while searching appeal information for Anthem. There is a condition called PANDAS, eating disorders are common manifestation. It is an infection triggered (most commonly strep) misguided autoimmune response.

  6. Thank you for sharing your story – so happy you won the battle.

    We are at the early stages of such a likely battle for one of our children – can I ask where you got the medical necessity criteria from?

    That would be really helpful I think in proving to them what’s really going on; but the criteria aren’t available online. (They say they use the MCG criteria, but those are only available if you pay a lot of money to the publisher.)

    Unfortunately, some providers aren’t good at making the case clearly to BCBS – they emphasize the wrong things and present the case unclearly – so we have to do a lot of advocacy ourselves.

  7. Thank you so much for this post!! It encouraged me to fight for more days of treatment, and I just got them! (without even having to do the external appeal, though I was ready 🙂
    I have been pouring over your blog – I LOVE your title and I can relate to SO many of your articles. Thank you so much for being willing to share.

  8. This comment is a little off-topic as it doesn’t involve eating disorders or current treatment, but it does involve coverage & fighting BCBS, so here goes….

    My wife had BCBS through her father, who worked for the government. She was admitted the the hospital for pregnancy complications & the insurance approved everything. Her father died while she was still in and shortly after we had our daughter. Everything went well and we moved on. Four years later, we received a bill from her Dr. asking for ~5k because Blue Cross had reversed its decision to cover her, due to her father dying while she was under treatment. We are now awaiting a massive bill from the hospital as well, since it was a month stay. We’ve looked & all of this is legal despite the obvious immorality and unethicality of it.

    Should we lawyer up and get ready to fight Blue Cross? Should we ignore the Dr’s bills and the hospital and say “Sorry, we were approved and we aren’t paying that”? Should we attempt to fight BCBS ourselves and deal with it via the insurance co staff?

    PS: Can I retroactively reverse my signed agreement with Blue Cross for MY insurance that I paid for? Can I reverse all the payments that came out of my paycheck? How are companies like this allowed to do this?

  9. I tried to do this without a lawyer and got creamed. Then I was told to contact this guy.

    https://twitter.com/DjHoltLaw

    I had a year and one half battle with BCBS in MN. Winning was (I guess) so surprising it made the news. Check out KARE11.com and search my last name Craswell. My issue was with an in network provider look up system that told you one thing when you were shopping a policy and a different thing once you had a membership card and had (ever) checked in. In fact it kept track of you by matching ip addresses so the only way to see it act up was to go to a different location / computer. Ditto on needing a lawyer. I thought this was so obvious it couldn’t be denied. Anyway – looking for others in MN with out of network bills they didn’t expect. I’m happy to provide them a technical explanation. Probably of more use is to contact my lawyer. I think he is a one man gang vrs the bus loads of lawyers BCBS loads up with. j.craswell at the Gmail account is a good way to reach me. If you had the consumer value network plan get ready for the pain!

  10. Can I simply say what a relief to seek out somebody who really knows what theyre speaking about on the internet. You undoubtedly know methods to convey an issue to light and make it important. Extra people have to read this and understand this side of the story. I cant believe youre not more widespread since you positively have the gift.

  11. To Jay Craswell…

    Apparently this isn’t just happening in Minnesota and isn’t just some “glitch” but sounding like possibly SOP for getting out of paying claims.