Healthcare 101 - Complexities and Creative Resolution

Mauree Miller

          Dealing with consumer issues in healthcare is in a league of its own.  While some of the issues are similar to those in other areas of business, making sure that you are getting the right coverage and avoiding problems and unexpected bills requires more special attention to details than with many other businesses.   Because of the complexity, when I work in healthcare, I often collaborate with colleagues to cover the many issues that can arise when a service is not handled correctly.  Several months ago, a colleague was assisting an individual in obtaining coverage that had been denied by her insurer after her child was born.

          The scenario:  Mom was covered under the insurance plan offered by her employer.  Dad was covered under his employer’s insurance plan. So, we have two different insurance companies in one family.  When they found that she was pregnant, the couple decided to cover the baby under Dad’s plan.  They checked out pediatricians under his plan, and were satisfied that there were sufficient resources available.

          Mom had made sure that all of her maternity care was within her insurer’s network and would be covered.  Logically, the couple believed that when she delivered, the baby’s care would be covered also. Wrong assumption.  They didn’t realize that there was a problem until months later, when they started to receive bills for the baby’s care in the hospital. They started to work with my colleague to resolve the bills.  It took months to find the source of the problem.  Dad’s insurer refused to pay the claims, taking the position that the law in their home state defaulted to Mom’s coverage for the baby for the first 30 days of life.  But, remember, Mom and Dad had chosen Dad’s coverage for the baby, and Dad had made sure to let his Human Resource Department know when the baby was born.

          The key to resolution was to clarify which insurer was really responsible to pay the claims. My colleague went back to Mom’s insurer, who wouldn’t pay the claims, taking the position that the baby was covered under Dad’s plan.  Dad’s plan said that it didn’t matter that Dad had arranged coverage under his plan.  They went back to State law to point the finger back at Mom’s plan.  My colleague worked very hard for many months to resolve this—through Customer Service and up to supervisors and managers in both companies.  She even managed to get a conference call going, so that managers in both insurance companies would talk to each other to resolve it.  Nothing worked.

            What happens when all avenues appear to be exhausted and there is no resolution?  Unraveling the problem, it became very clear that Mom’s plan was not responsible for coverage, because her plan fell under Federal law, and the State law didn’t apply, so that Dad’s selection took precedence.  Reviewing Mom’s plan documents, there was not an automatic default to her plan for the baby’s coverage during those first 30 days. This was an uncommon situation, and Dad’s plan was operating under a common assumption, not on the facts.  We needed to find an escalated contact with Dad’s plan. The goal was to convince the right person in Dad’s insurance company that Dad’s plan applied. This could only be done through a high level contact.  How would I find that contact?

            Dad’s insurer operated in several states.  Their most prominent presence was in another state rather than in the state where Dad’s plan was written.  I had a contact in their main office, and started by calling her.  She couldn’t help me.  Often, one site will have a directory for other sites.  Not in this case—each state site was independent..  How could I get past this impasse?  I played on the computer—I Googled Dad’s plan in the state where he lived, and came up mostly with a bunch of nothing.  BUT, buried in the entries, I found a press release from Dad’s plan in his state, several years old, but with the name of a Media Relations representative and her phone number.  This could have been a dead end, but even if the same person wasn’t still there, I probably could get into the Media Relations area.  How could Media Relations help me?  Media Relations is concerned with presenting a good public image.  And, someone in that department would be in a higher level position, rather than in a line/Operations position.  In other words, they could hopefully think more broadly about company profile, rather than getting bogged down in detail.  This could motivate them to get me to someone who could help. I called the Media Relations number and reached a voice mailbox for the Media Relations contact from the article.  I left a message, in a polite but authoritative tone, simply introducing myself and saying that I was working on an issue that wasn’t resolving through normal channels, and that given the human interest/healthcare nature of the problem, the best public relations action would be to get me to someone in the Executive area of the company so that we could resolve it.  My point was to leave just enough information to tantalize, and to be clear that I needed to work with someone at a high level who would be savvy and empowered to resolve a situation that had created ill will for the member.  It worked!  I had a call back the next day from someone in the Executive Inquiries area.

            Anna was the escalated contact.  She and I developed a close and very long relationship on this case.  It still took a few months to resolve.  Anna and I collaborated well, but even with a dedicated escalated contact, it still was complicated.  I had to produce Mom’s contract that would prove that her plan wasn’t responsible for coverage.  Anna worked for Dad’s plan, and their Appeals Department had already determined that the plan wasn’t responsible for coverage, so Appeals had to come back into the picture.   Legal and Claims Departments had to be consulted. Despite the fact that Anna understood the issue and was acting as an advocate, many departments had to weigh in.  Finally, everyone agreed that, yes, Dad’s plan was the responsible plan.  Glitch---the services used were in Mom’s network, but not in Dad’s network.  Dad didn’t have any out of network coverage.  After much negotiation, Anna and I agreed, and were able to convince the decision makers that “stuff happens”.  “Stuff happens” is not usually a winning argument. But, with a year under our belt and mistakes all over, this gave us some clout.  The powers that be finally agreed to pay the baby’s claims.  By this time, the baby was a year old.  But, we did get the charges covered, even after all of this time.


1) Know the rules of your plan. 

2) If you’re not sure of the rules, and even if you think that you are sure, call your insurer before the service to verify that you are taking the correct steps to assure coverage.  (And, of course, document your call details so that you have a quick reference if there are problems on the back end.)

3) If you hit a snag, make sure you do your research to make sure that you are on solid ground in arguing the issue.  You can’t convince the other party if you don’t have the facts and if you are unclear.

4) When it gets complicated, you will need an escalated contact in an area dedicated to solving complicated problems.

5) If you can’t find that escalated contact through standard channels, get creative, and look outside of the obvious. Who would have thought to look at an old press release to resolve an Operations/Claims problem?  And, make sure that you present the issue so that the contact sees that it can have impact on their area. The face of the company and avoiding ill will is the purview of Media Relations. With that in mind, there would be motivation to involve someone who can solve the problem.

6) Even with what appear to be overwhelming obstacles, if you know that you have a reasonable point, keep going.  Persistence pays off—though this one took a year.

Now, Happy birthday, sweet little baby! Congrats to Mom and Dad!  As for Anna and me, we think that after finishing this messy problem, we probably have the skills to solve world peace.