Grudge Match: SJG vs. The Insurance Company

Have you ever seen the movie "The Rainmaker"?

If you haven't, go watch the trailer right now. Because if you're planning to have a vestibulectomy, you are probably going to end up living your own version of "The Rainmaker."

You would think that it would be simple. You're on insurance which only allows you to go to in-network providers. So you go through the complicated, difficult process of getting a Clinical Gap Exception, which means that your operation will be considered an in-network procedure. You shell out the money (in this case, $9000) to Dr. Goldstein and then you file your claim in order to get reimbursed. My in-network plan covered me 100%, so I was owed a check for $9000.

Here's what actually happened:

1) United Healthcare never received my claim when I mailed it to them.
2) I faxed it to them three more times and it took three times (and two different fax numbers) for them to finally receive my claim. They refused to allow me to send it to them by email (which would enable a person to say they had actually gotten it) because they are "not set up to handle claims by email."
3) They denied my claim, saying that I had had my procedure out of network.
4) I showed them the letter they wrote me in which they said that they would cover my procedure at the in-network level because they lacked specialists and doctors who could perform the procedure.
5) People at United Healthcare were completely incompetent and couldn't read English. First, they said I never got a clinical gap exception because they looked at the wrong one (the one that I had tried to get but which had been shut down because I did not provide the proper CPC codes at that time). Then, when I directed them to the correct one, they said their original letter meant that only the procedure would be covered, but not the doctor. I asked them how exactly one could have surgery without a doctor performing it. Then they said that I was supposed to have my procedure on March 1st and I was in violation of the gap by having my procedure in June. I pointed out the letter they mailed me giving me permission to have the procedure was postmarked March 4th, so that made no sense, and that I had, from the very beginning, said I was going to have my procedure in June. Then they said the letter I received wasn't a Clinical Gap Exception. I asked them why it had the word 'Gap' on it. Their bottom line was they couldn't help me and my claim was denied.
6) I submitted a Letter of Appeal explaining exactly why I was owed the money.
7) The Letter of Appeal was denied because I had had an "out of network procedure" and therefore had to pay for everything myself. It was like they didn't even bother to read anything I had written in the Letter of Appeal.
8) I spoke to a Rapid Resolution Specialist and other high-up United Healthcare people and referenced my Clinical Gap Exception, which was in direct conflict with the denial they had sent me. Lower-down people at UHC sympathized with me and said so, but the higher-up people just issued flat denials or made it seem as though I was somehow at fault for their inability to honor their own clinical gap.
9) I filed an appeal/ letter of complaint with my State's Insurance Administration.
10) The State spoke to United Healthcare and told them what they were doing was wrong, illegal, and they had better pay up. (At least, that's what I assume they said, because absolutely nothing had changed from when I talked to UHC and when they talked to UHC).
11) I got a letter from UHC in the mail which read exactly the same as the letter that I originally received to tell me that my Letter of Appeal was denied, but which said 'CORRECTED LETTER' on top and had two lines that were different. The first line told me that my claim would now be covered. The second line apologized for the inconvenience.
12) I got my $9000 check.

As you can see, I went through A LOT of heartache and hassle to finally get my check. It took 5 months from the time of my surgery for me to get my check, and it was only that fast because of my constant badgering of the insurance people and my prompt filing and faxing of claims and letters of appeal. These were five months of constant mental anguish, agony, and frustration, worry that I would never get reimbursed and would owe the people I borrowed money from $9000, and concern that I would need to hire a lawyer and actually sue UHC in court. I think everyone would agree that it should not be this hard to receive money you are legitimately owed.

In order to make sure that you don't have this happen to you, you need to insist that when they give you a Clinical Gap Exception, they write into the Clinical Gap Exception the date you will be having the procedure, who you will be having the procedure with and where it will be held. That way, they cannot claim later on that they had issues regarding the 'date of service' and that you were supposed to have your procedure on an earlier date. Also, save every single document they send you, because you are going to need to be the one to have the service numbers and claim numbers to reference to the incompetent employees who man the phone lines. But even with that, you will probably end up in a situation like mine, having to sic the state on them before they pay up. (And you will only be allowed to do that after having exhausted every single possible other option, which means you'll have to go through the writing of appeal letters first, etc). Because insurance companies (and especially United Healthcare) make money off of being evil, and off of hoping that people will simply give up after their claims are denied time and time again. And I'm sure many people do give up. I couldn't afford to, because it wasn't my $9000 to give up on- I had borrowed it from, and owed it to, someone else.

You can see the full story of all the nonsense that happened until the point where I had to file an appeal with the State's Insurance Administration in my Letter of Appeal (which was originally denied, but which I had fun writing) below:

September 9, 2013

Letter of Appeal to Claim #

To Whom It May Concern,

This is an appeal to Claim #__________. My name is SJG. My current UHC Member ID is _______ and my birthday is _______. Upon marrying my husband, I discovered something quite upsetting- I could not have sex. This was not because I did not want to have sex, but because sex was excruciatingly painful for me. After seeing seven different doctors, I finally found a specialist who could diagnose me. I was diagnosed with congenital neuroproliferative vestibulodynia (which means that I had a birth defect of too many nerve endings in the vestibular region of the vagina). A highly specialized surgery called a vulvar vestibulectomy was called for.

At this point in time (during the 2012-2013 year) I was on a UHC HMO plan. This meant I could only see doctors in-network. Unfortunately, no in-network doctor could perform such a highly specialized surgery. This meant that I needed to contact United Healthcare to file a clinical gap exception. This was a mysterious process not explained clearly anywhere on your website, but I managed to learn that my primary physician, _______, needed to call you to explain that she had referred me to Dr. Andrew Goldstein, a doctor who could perform the surgery in question. She needed to call United Healthcare Care Coordination at 1-800-638-7204, explain that she was calling on behalf of SJG, whose member ID was _____ and explain that I would be having surgery as an OUTPATIENT procedure on ________, at 7:30am at the ______. She called sometime during the week of February 18, 2013 and provided United Healthcare with all of this information.

Unfortunately, at the time that Dr. _________ called, she did not provide United Healthcare with CPC codes for the procedure in question. Therefore, they shut down this first attempt at getting a Clinical Gap Exception and did not notify me (or her) of the fact that they had shut it down. Only after I called to follow up did I find out that this first attempt had been shut down. I then called Dr. ________ again, gave her the proper CPC codes, and she called United Healthcare again. This time, the clinical gap exception was approved.

I received a letter dated March 4, 2013 with the Service Reference #_______ indicating that my clinical gap exception had been approved. (A copy of this letter is included in the documents I am faxing to you). This letter began with the paragraph:

“On 3-01-2013, we reviewed your request to cover Vulvar Vestibulectomy for you provided by Andrew Goldstein. We are pleased to inform you that the health care services will be covered at the network level. Although Andrew Goldstein are outside your health benefit plan’s network, we will cover the services at the network level because at this time we do not have a physician, facility or other health care professional within your network or area to provide these services.”

For the 2012-2013 year, my in-network coverage rate was 100%. (Please note that this has changed, because my plan has changed. The plan I am currently on, for the 2013-2014 year, and which began on ____, 2013, is a HSA plan, and therefore has different coverage rates.) The letter mentioned above indicated that my Clinical Gap Exception would therefore cover the entire cost of my surgery. Overjoyed, I called United Healthcare back to check that this was indeed what the letter meant and that I would be fully covered. The customer representatives that I spoke to assured me that this was the case.  You are welcome to pull the phone calls that I made from the phone number _________ and listen to them to see this is the case.

On ________, I did indeed undergo surgery with Dr. Goldstein. I paid $9000.00 out of pocket to the doctor, and obviously wished to have this reimbursed at the in-network level as I had been promised. In early July, I received the pathology report and results of the surgery from the doctor. On July___, I sent the claim form, Letter of Necessity that Dr. Goldstein had provided, Clinical Gap Exception letter and pathology report to the PO box for medical claims listed on the back of my United Healthcare card. I waited and waited, but heard nothing about my claim. A month later, I called and discovered that UHC had never received the claim. I requested to send it in by email so that I could confirm that someone at UHC received it, but was told that UHC was not currently outfitted to receive claims by email. I therefore resent it on August ___ to the fax number 248-733-6000. When I called to follow up, UHC had still not received my claim. I then resent it to the fax number 612-234-0295 on August ___.

At this point, as you can imagine, I was extremely frustrated that I had had to submit my claim three times for UHC to finally receive it. I then received a letter via the mail with the Reference # __________________. This letter stated “we reviewed your request for you for $9000.00. Unfortunately, we do not have a record of a claim for this amount.” Since I had submitted my claim for the third time I knew this could not be correct. I immediately called UHC to follow up. At this point, I was told that my claim could not be processed because my clinical gap exception had not been approved. This was incorrect; the person on the other side of the phone was looking at the first attempt at filing a clinical gap exception which had been shut down due to the lack of CPC codes. She was not looking at the later attempt at filing the clinical gap exception which had been deemed correct.

Once the fact that I did indeed have a valid gap exception was sorted out, the person on the other side of the phone told me that the words “On 3-01-2013, we reviewed your request to cover Vulvar Vestibulectomy for you provided by Andrew Goldstein” meant that the date of service for my surgery was 3-01-2013. I attempted (to no avail) to explain to the representative that she did not understand the English language. The fact that UHC told me that they reviewed my request to cover surgery on March 1^st does not mean that the date that I would actually have the surgery was on March 1^st. The representative told me that I should “change the first lines of the letter” and resubmit it as an appeal. This made absolutely no sense because I cannot simply white-out lines of a letter that UHC sent me and pretend that you reviewed my request for the clinical gap exception on __date of surgery_when you reviewed it on March 1^st.

I called back UHC today, September 9, 2013. I was transferred to a male regulator named Lynn who informed me that an error had been made by UHC in UHC’s system. When UHC input the date of service for the clinical gap exception, they erroneously indicated that it would take place on March 1, 2013. While inpatient procedures can apparently be changed by regulators, outpatient procedures cannot. Lynn therefore advised me to write you this letter and send you all of my documentation to request that you a) change the date of service in your system for the clinical gap exception to _date of surgery_and b) please reimburse me for the $9000 I have paid to have this surgery.

In addition to this letter explaining everything that has occurred, I am sending you documentation that includes:

·         My Claim Form

·         My Clinical Gap Exception

·         A Letter of Necessity explaining why I needed this procedure and which CPC codes were used

·         Receipt for Surgery

·         The Operating Room Report, explaining my diagnosis and the doctor’s findings

·         The Pathology Report, which indicates that I did indeed have congenital neuroproliferative vestibulodynia.

I have spent (at minimum) a good ten hours of my time attempting to submit this claim in a way where you would actually receive it, having phone conversations with various incompetent UHC representatives and now writing this appeal to you. Please honor the Clinical Gap Exception you provided me with and reimburse me for the $9000 that I spent in order to be physically able to have sex with my husband. I would also appreciate a letter of apology for all of the aggravation that I have been caused for errors that were made by UHC during this process (these include: not looking at the correct clinical gap exception, not knowing how to read English, suggesting that I white-out and forge parts of my Clinical Gap Exception, apparently putting the wrong date of service into the system.)

If you have any questions, or are confused by anything I have written, please call me at ___________.

Thank you,

SJG