As she prepared for ankle surgery, Deborah Davis called her health insurer to make sure she was covered.
She told the Harvard Pilgrim Health Care representative the name of her surgeon, and after a quick check, the rep replied that, yes, he was in her plan. You’re all set, the rep told her.
Months later, after running into problems with Harvard Pilgrim, Davis provided me with this account of her dealings with her insurer, beginning with her asking the representative: “Is there anything else I need to know?”
“No, as long as the surgery is done at a day facility, you’re covered,” the representative said.
Davis had her surgery at New England Baptist Outpatient Care Center in Dedham. That wasn’t her choice, exactly. It was where her surgeon set up the appointment for Jan. 22. But it was fine with her. After all, it was a day facility, and that was the only requirement for coverage, as she understood the process.
On the morning of the surgery, Davis paid $200 as a copayment, which the Harvard Pilgrim representative had told her would be her total out-of-pocket expense.
A month later, she got a bill for $2,879.
Why? Because, she would later learn, she had gone to the wrong type of facility.
Davis and her husband, Glenn, have spent hours on the phone trying to get Harvard Pilgrim to take responsibility for the bill. They say the giant insurer failed to give her crucial information.
“I must have asked six times, ‘the $200 copay is the total cost?’” Davis said when we met in the couple’s home in Mashpee. “I wanted to make sure I wasn’t missing anything.”
Davis, 61, a retired preschool teacher, said she got the same answer every time: “As long as it’s at a day facility.”
There’s no question that New England Baptist Outpatient Care Center is a day facility, which is a term synonymous with “outpatient” and “ambulatory” facilities. There are no beds, no overnight stays at the New England Baptist Outpatient Care Center — not to be confused with New England Baptist Hospital, its inpatient affiliate with more than 100 beds.
As the Davises made calls to Harvard Pilgrim and New England Baptist Hospital (which handles billing for its Outpatient Care Center), they were told at first that coverage was denied because the bills came from a hospital, not an outpatient facility.
But that proved not to be the case. They were also told it had to do with the “coding” of the surgery and the facility. But that also proved not to be the case.
The Davises submitted a formal, written appeal. A month later, they received a denial, which looks like it contains a lot of cut-and-paste paragraphs. But what makes the denial letter really remarkable is that it contains not a single word dealing with Davis’s central contention that a Harvard Pilgrim representative gave her misleading and incomplete information.
Instead, Harvard Pilgrim seized on a distinction it makes deep in its “schedule of benefits.” It turns out, the insurer does not cover all day facilities. It covers only a handful for surgery, the ones it designates as “flex” providers. (I asked Harvard Pilgrim what qualifies a facility for “flex” designation, but it ignored my question; it also declined to provide other details I requested.)
Davis said that had she known better, she definitely would have gone to a flex facility, even if it meant finding a different surgeon.
So who’s to blame?
Harvard Pilgrim in its denial letter holds Davis responsible for knowing what’s in the schedule of benefits. That may be true if Davis had never called with questions. But she did. And I think she deserved a better explanation. The member services rep should have asked her where she was going to have the surgery and checked the flex list. I also think Davis should have volunteered the information.
Remember, the purpose of Davis’s call was to get clued in to exactly this kind of crucial information. She wanted to get her full benefit. Once Harvard Pilgrim took her call it was responsible for giving her complete and accurate information.
And Davis had a right to rely on what she was told.
Late last week, Harvard Pilgrim, besieged with questions from me, reversed course and agreed to cover the $2,879. I asked if it did so because it found fault in how it handled Davis’s claim.
No, it said.
I wonder. Davis had implored Harvard Pilgrim to check the recording of her calls (she said she made more than one call, in which she asked the same questions and got the same or similar answers).
A Harvard Pilgrim rep said she would “pass along” her request, and when she later asked what the recordings revealed, she said she was told, “I can’t tell you.”
Davis asked to hear the recordings, but Harvard Pilgrim said “not without a subpoena,” according to Davis.
I, too, asked what the recordings revealed, even after Harvard Pilgrim agreed to cover the $2,879. But it did not respond.
Managing health care insurance is one of the most daunting challenges consumers face. Here’s a bit of advice: Take notes, and keep them. When you are on the phone with your insurer, ask questions and jot down important answers (e.g., “as long as in a day facility all set”). One way to preserve your notes is to e-mail them to yourself. That fixes the date and allows you to later find them in your inbox.
Insurers keep a tight grip on their money. You should too.
Sean P. Murphy can be reached at firstname.lastname@example.org. Follow him on Twitter @spmurphyboston.