Blue Shield denies insurance coverage
Debbie called me yesterday shortly after they learned that Blue Shield had denied insurance coverage for Gracie's stay at Craig Hospital. After things had been progressing so well with a review by Craig (a nurse came out to evaluate Gracie), coordination with an air ambulance to take her there, and subsequent admission into the hospital, to be denied coverage by Blue Shield was a punch in the gut, to put it lightly.
Blue Shield suggested that they could appeal the decision, but the process could take up to 30 days! That's ridiculous, as her recovery is directly tied to getting into a rehabilitation program as soon as possible. The reason for the rejection, as I understand it, is because there are facilities in California that could provide treatment, but none of them provide the level of support and experience that Craig Hospital can provide. Three different doctors involved in Gracie's care have recommended Craig Hospital as her number one best option for rehabilitation.
Craig Hospital is a Blue Shield contracted hospital, so I cannot see why Blue Shield could not approve coverage. The Fishers have a PPO plan, not HMO, so they should have the freedom of choice. Yes, it is out of state, and yes, Blue Shield operates as different corporations in each state, but it's a national insurance organization, and no reason this cannot be worked out.
They are pressing Blue Shield to reverse their decision, but I wanted to get word out of this tragedy in the hope that perhaps someone knows someone at Blue Shield who might be able to take a special interest in this case. Craig Hospital is truly Gracie's best option, and I want to do anything possible to make sure she goes there.
If you have any contacts who might be willing to help out, or ideas on how to communicate this need to Blue Shield, I ask that you first make contact yourself so that you can decide if it would be helpful to Gracie's case... that would help me and the Fishers out a lot by doing some of the initial legwork for us. If it proves to be useful, please email me details at [email protected] and I'll collect them, process, and forward onto the Fishers. Thanks in advance for your help in this.
Finally, regardless of it you contacts or resources or not, please pray about this. We do not always know God's ways, but I would ask for understanding, sympathy, and grace on the part of Blue Shield so they can see the wisdom of reversing their decision.
Paul
Update 2:31pm: I have contacted all of the local press organizations and KEYT. I've also contacted LA Times. I am working to provide them with details on the situation. Thank you all for your comments and suggestions.
Update 4:57pm: there have been a number of very good questions regarding policy coverage, out-of-state coverage, type of plan, and other things that play into the process. Some of them I have answers for, others I do not. I will post the details once I receive them in a new journal entry.
Comments (28)
This is rotten news. So sorry, but will think positively.
Paul, There are two additional things that they may want to consider. A) Register a complaint with the insurance commissioner for State of California. B) Alert the media. Literally. Put together a PR campaign that will give Blue Shield a black eye. Go beyond that Santa Barbara market if you do this -- and make it at least a regional if not statewide story. Hope that helps, Neil
Hi Paul, we have had individual insurance (PPO) for years with Blue Shield and have had to fight with them multiple times to cover things they should have. I have directly called the CEO's office and the admin gave me someone to work with in the Grievance department - this is a great place to start. I was diplomatic, but relentless, which I have to say is what they responded to. They really hope you will go away. I have even had them say they absolutely won't cover something only to see them cover part of it. Use their words against them. They can't back up that she will get the same care because doctors in CA don't have any real experience with this disease, Craig Hospital does. Through my experience of having to go through grievances 3-4 times no doesn't mean no. Use the media for sure. When folks see Gracie's photo and hear her story they will all want to help. Start with the journalist who wrote the first article about Gracie. This could be a media nightmare for them and they know it, they are waiting to see what you do. I am going to contact a friend who owns an insurance company here in the bay area and is also in politics to see if he has any ideas. I will come back and post what I know. Good luck and let me know if I can help. I can be a good pit bull when the cause is right. ;-)
Paul, I made a quick phone call to an industry person I know see if there's any more information. A couple of things I was told. 1) If you are under a newer ACA plan (Obamacare), there's no out of state coverage except for emergencies (i.e., you have to go to an emergency room). This applies to most individual plans, but if you have a small group or large group plan, you may still have interstate coverage. You need to check. 2) The cost of transport may be your key issue -- it's expensive, and therefore may be key sticking point. If you can figure out how to do that differently, that may help. 3) When you make the case to Blue Shield, it may be that care in Denver is a LOT less costly than in California -- so you may be able to make the case to Blue Shield that it's to their financial advantage to cover in this way. Hope that helps, Neil
Yes, I agree file a complaint with the insurance commissioner and get this story to the media outlets Also, shaming Blue Shield into reversing their decision through social media...Facebook - Twitter. We're going to try to pass it on to KFI's John and Ken Show here in LA and Tom Brokaw who is battling multiple myloma and has a radio spot called An American Story. Immediate publicity. Does anyone have a contact at Huffington Post?? Also get the state and local politicians involved - it's an election year!!! This is a story that needs to go viral... An interview with the family videoed and posted to YouTube that can be reposted to FB. Jam their circuits - give out the Blue Shield Phone number and fax - get a campaign going. I work with insurance companies all the time and it is about climbing the chain of command and never letting up until you get to the person who can make the difference. God is able to do an end round around anyone and it doesn't have to make any sense! Persist, Insist...etc. Keep letting us know how we can help!
I emailed CJ Ward at KEYT this story idea for his Tipline Investigation segment - they're great at getting movement and good resolution. I'll keep you posted on his reply.
I spoke with a friend in publicity who recommended definitely going back to all the outlets that have posted stories about Gracie and getting their investigative teams involved. These news teams have already been involved and have all the facts they can pass along to any larger news outlets. It makes me feel a little better reading all these comments and suggestions and knowing people are already working on this for the family. I will continue to pray and spread the word.
Would it help if we all sent emails to C.J. Ward and Beth Farnsworth at KEYT TV or would that be a bad idea? No experience with this.
How can I get in touch with you?
I work for Anthem Blue Cross. Send me your number and I can add some input
Wrote to Ariana Huffington, a few politicians and other visible people and also contacted legal....
Paul, I'll make a call yto our local Congressional office to bring their attention tto the matter. If you or anyone else, for that matter, would like to do the same, here's the number: (805) 730-1710
I have been in insurance sales for 40 years. I hate the health insurance business and escaped 4 years ago. I do know that Blue Shield is a different company in each State in which they operate. This is probably the crux of the problem. It may be best to have her seen at a California based rehab hospital first and lobby her doctors to make the strongest recommendations to have her transferred to Craig. This will accomplish several things. First, you will be complying with their rules which takes the situation from an adversarial to cooperative. That also changes the argument from you not wishing to comply with their requests to upgrading her care for a rare illness that can be best treated elsewhere. Secondly, it gets her into some form of rehab right away. Thirdly, it allows for time to create a media storm to put pressure on Blue Shield to change their mind. As one who has made it my life's journey to fight city hall, I have found that this is not an effective way of dealing with the decision makers at insurance carriers. I would call Lois Capps office in Santa Barbara at 805-730-1710 and let them know what's occurred and ask for their immediate intervention. We are praying for you all. Please call me if I can be of any further assistance. 805-845-2377 Peter Lyman
Update 2:31pm: I have contacted all of the local press organizations and KEYT. I've also contacted LA Times. I am working to provide them with details on the situation. Thank you all for your comments and suggestions. - Paul
That's the problem. Pres Obama should have spent a lot more time investigating the health care solution instead of pushing his political agenda. Insurance Companies all need to be not for profit AND, not public companies. How can they keep their rates low and bring a return to their investors! Additionally we should be able to purchase health care policies across states to keep these companies from having a monopoly. Finally, both Insurance Companies and Hospitals (many of whom are supposed not for profit)need to have their executive perks and salaries regulated. It is disgusting that these execs earn $1mill plus!!!! Nobody's job is that important! Health care agencies and insurance companies are making out like bandits! Only the doctors are getting screwed.
Update 4:57pm: there have been a number of very good questions regarding policy coverage, out-of-state coverage, type of plan, and other things that play into the process. Some of them I have answers for, others I do not. I will post the details once I receive them in a new journal entry.
I am Debbie Fisher's employer and Grace Fisher's insurance is covered under our plan. Debbie and I have been in direct contact with our local insurance broker. She has written and submitted an insightful and positive letter to some key players at Blue Shield to provide information on Gracie's condition and requested that their decision be reversed. In her letter she mentioned that this community and many others in the U.S. are rallying behind this individual. She mentioned that time is critical and urged action much sooner than the standard appeal process of 30 days. Hopefully Gracie's physicians have also submitted letters directly to Blue Shield. Let us all pray for a the Lord to work on the hearts and minds of Blue Shield executives who can reverse this initial decision and allow Gracie to be admitted to Craig Hospital.
Has anyone talked to the insurance administrator at Craig? They treat people from all over the country and he/she may offer some valuable ways to combat this problem. I'm sure it has occurred before. The care at Craig may end up being less expensive in the long run because they have so much experience that no time will be wasted. They'll know exactly where to start and how to maximize the treatment time or get her started on a program that could be continued in California. Has one of the doctors talked to the "head Fred" at Blue Cross? Sometimes a personal talk with a real person who can actually do something helps. I once got a child approved for a brand new brain surgery at an out of network hospital by appealing to the director with "what if this were your child". He decided to approve it. Does anyone know a way to get Oprah involved? She's a member of your community and may find some way to help. Thank you for taking this on. We all want the best for Gracie and will continue to pray for her, the family and you that all this will seem like a small bump some time soon.
I love the idea of a video on this issue. Friends, family, church... whatever works. Yes, post on YouTube but also alert us so we can "share" on FB. Continual prayers and much love.
WE ALL THANK YOU i KNOW.
hi gracie i hope you get better soon we are praying for you and are very worried about you -love aidan p.s. i am playing the bach arioso and think about you when i play it
Oprah contact really could be a great move! Here is her Santa Barbara address: 1633 E Valley Rd Santa Barbara, CA 93108-2104
Everybody call the Department of Managed Health Care and the insurance commissioner. And make sure the family calls too. Also, I'd be happy to help set up a Change.org petition. Or somebody else could set it up, as I've never done one, but I'd be happy to learn.
I second Isaac's idea of Change.org and I might suggest considering a Heath Advocate. They specialize in getting insurance to provide coverage they should. So glad to see so many are working on this!!!
I created a petition on change.org and posted it on Facebook. Pls ck under Lea Williams. Unfortunately I had no photo to add. If you have a link for that, pls send to me at [email protected] and I'll then add. Pls also let me know if the petition should be altered. Thank you to Isaac for this idea. Much love to you all.
Following Lea, I posted a petition to Blue Shield on behalf of Gracie also. It is very easy to do. I am betting that copies are sent to Blue Shield. We might be able to get some traction with mass postings on change.org. I wish "60 Minutes" would do a segment on this, but it's too urgent for their programming. It seems like justice or "doing the right thing" only comes from pressure via the mass media exposure of bad practices. Following Issac, I read some reviews by employees and former employees of HealthAdvocate.com and decided not to approach them,--it is a commercial a "claims mill" that doesn't have enough time to really pursue an issue. I looked at the California State Insurance Commissioner's site,--it seems to be more concerned with licensing issues,--we would probably have to claim that Blue Shield is doing something that should cause their license to be pulled. I think that's not the case.