Untangling health insurance troubles

Every week, I get at least a dozen queries about health insurance from readers like these: ¶ “Dear Lisa, my husband is scheduled for a colonoscopy . . . . We told the doctor he wants to be put under with anesthesia, and they said our insurance doesn’t cover it.” ¶ Help. ¶ Then there was the man whose fiancee was having “enormous problems” getting bills paid from December, and “every time we call we get the run-around. No supervisor is ever available to speak with us.” ¶ Help. ¶ It’s no wonder my e-mail box runneth over with such pleas. Over the last five years, California regulators logged nearly 100,000 calls and nearly 50,000 formal complaints against health insurers -- HMOs and PPOs alike -- over problems such as unpaid claims, treatment denials and poor attitude. ¶ That might not seem like a lot when you consider that there are more than 20 million Californians with private health insurance. It is perhaps more troubling, though, that complaints have gone up even as the number of insured Californians has declined. Last year there were 12,109 formal complaints, up more than 30% from 2003. ¶ Regulators and law enforcement officials on both coasts have taken note. They have opened several investigations that go beyond sorting out individual problems and are looking into the possibility of systemic illegal practices that result in consumers losing coverage, paying more than they should or not getting the medical care they need. So stay tuned.

Of course, when you can’t get your insurer to approve the surgery your physician says your child needs, you want help and you want it now. It is not always easy to solve these problems on your own. If there is one common thread throughout the e-mails I receive, it is frustration -- often to the point of exasperation.

A nationwide J.D. Power & Associates survey last month may help explain why. It found that only 45% of health plan members reported that they fully understood how to use their coverage.

California health plans did not fare well in Power’s second annual consumer satisfaction survey. The notable exception was Kaiser Foundation Health Plan Inc., which received top scores from members. Cigna got an “average” rating. The rest -- Blue Shield, PacifiCare, Anthem Blue Cross, Aetna and Health Net -- all received sub-par scores from their members.

Reader e-mails give me a consumer’s-eye view of what is driving these sentiments. They present me with endless story ideas and help me sort out which ones seem to be most pressing.

It’s impossible for me to respond in detail to each e-mail I get. But when the stakes appear serious, I often pick up the telephone. I do this because it is important for me to understand how the companies and the regulators work. I also jump in because, no matter how pressing my next deadline is, it is hard to turn my back on people in such dire straits.

That’s how I felt when Nancy Kolodny’s e-mail showed up in my in box. The former Countrywide Financial Corp. executive reached out in a panic after she was dropped from her COBRA health plan and left without coverage for the first time in 30 years.

Kolodny, who suffers from a rare genetic disorder and is dependent upon a $22,000 enzyme treatment every two weeks, was told that her last payment on her health plan was $71 short. She says she never got the notice that the plan administrator claimed to have sent informing her of the $71 premium increase.

Hoping to get her coverage back, Kolodny sent in the difference right away. But it was too late -- a day past the grace period. Sorry, they told her. There was nothing they could do. That’s when, in desperation, she e-mailed me.

Please help.

“I’ve never been delinquent,” Kolodny said. “I am a really responsible citizen, and I’ve never gone without insurance. I’ve made sure I always had work. I’ve made sure I always had insurance so I could protect myself and my family.”

Kolodny was afraid that she would not be able to get her next enzyme treatment and that her health would deteriorate. So I started making calls.

Her case was complicated. It involved her former employer Countrywide, the Calabasas-based home financing company that is being acquired by Bank of America Corp. in the wake of the mortgage meltdown. It also involved an Orange County firm that administers Countrywide’s health benefits for former employees.

I left messages at both companies.

Then I turned my attention to COBRA, the acronym for the Consolidated Omnibus Budget Reconciliation Act of 1986. COBRA is the federal law that requires companies to allow departing employees to continue their health benefits at their own expense for 18 months. (A California law known as Cal-COBRA can extend this coverage for another 18 months, for a total of three years.)

As if healthcare weren’t complicated enough, Congress decided to split jurisdiction for COBRA between the Labor Department and the Internal Revenue Service.

I placed calls to both agencies.

Gloria Della, a spokeswoman for the Labor Department in Washington, explained that her agency takes the lead in addressing consumer questions and problems.

“We deal with this kind of stuff all the time,” she said.

Della said she wasn’t sure whether, technically speaking, anyone had erred in dropping Kolodny. But she said the department could help sort it out. Della recommended that Kolodny call the department’s regional field office in the Los Angeles area, and she gave the local office a heads-up.

Kolodny called, prompting the department’s local office to get in touch with Countrywide. And, almost immediately, she was reinstated. According to Countrywide, as soon as the problem was brought to its attention, Kolodny’s appeal was heard and decided in her favor. Problem solved.

Kolodny says she hopes her story helps others.

“It’s important that people know they don’t have to take ‘no’ for an answer,” she said. “There are things they can do.”

But figuring out where to turn for help is confusing because, as Kolodny’s case illustrates, health insurance is overseen by a tangled web of regulators. So, I decided to compile my first guide to health insurance to point as many of you in the right direction as possible.

Getting help with health insurance problems

* Your health plan

Often, problems can be easily solved by your health plan. And this is often the fastest way. Your wallet identification card or policy should give you a telephone contact for complaints. If you are unsure about where to go, the California Assn. of Health Plans, a trade organization representing the companies, keeps a list of contact information for most of the ones operating in the state. You can find it on their website at www.calhealthplans.com.

If you have no luck with your insurer, state and federal regulators may be able to help.

* California Department of Managed Health Care

More Californians are enrolled in health plans overseen by this state agency than any other regulator. So it is most likely to have jurisdiction over your health plan. And even if it does not, the DMHC will help you figure out which agency does. Last year the DMHC referred more than 4,600 calls to other agencies for help.

The DMHC licenses all HMOs, or health maintenance organizations, and several PPOs, or preferred provider organizations. This agency can help consumers, as well as physicians and hospitals, with problems getting medical care, disagreements over covered benefits, problems getting referrals to specialists, denials or delays of payment, billing errors, cancellations and more.

The agency’s help center is open 24 hours a day, seven days a week. Consumers can call (888) HMO-2219. Complaints also may be e-mailed to helpline@dmhc.ca.gov; mailed to 980 9th Street, Suite 500, Sacramento, CA 95814; or faxed to (916) 255-2292. Its website, www.hmohelp.ca.gov, provides valuable information as well.

* California Department of Insurance

This agency can help you with questions and problems regarding health coverage underwritten by an insurance company. It also has jurisdiction over some long-term care policies, some Medicare Supplemental plans, and some dental and vision coverage.

The best way to determine whether this agency has jurisdiction over your coverage is to pull out your policy or wallet identification card. If the name of the health plan or insurer includes the words “insurance company,” it probably falls under this department. If you aren’t sure, the department’s Consumer Communications Bureau can help you.

The bureau’s hotline responds to 300,000 inquiries a year about issues including the availability of insurance and COBRA. It investigates complaints involving claim delays, denials of coverage, disputed benefit amounts, medical necessity, refusals to insure and continuation of coverage rights under state and federal laws.

Consumers, physicians and hospitals can contact the department’s Consumer Communications Bureau at (800) 927-HELP (4357). Helpful information, including request-for-assistance forms, also may be found at the department’s website, www.insurance.ca.gov.

* U.S. Department of Labor

This is the place to go if you have coverage for which your employer assumes the risk. These so-called self-funded plans usually are administered by insurance companies such as Aetna, Cigna, Anthem Blue Cross and Blue Shield. But those companies merely process claims, adjudicate treatment disputes and lease physician and hospital networks for the employers.

Many large private employers, such as Tribune Co., parent of the Los Angeles Times, offer health insurance in this way.

The Labor Department also can help with questions and problems with COBRA coverage. Consumers may call the department’s Employee Benefits Security Administration for help at (866) 444-3272. In the Los Angeles area, consumers also may contact a regional field office at (626) 229-1000.

The department also offers information about health insurance and other employer-sponsored benefits on its website at www.dol.gov/ebsa/.

* Other resources

Every state has different laws and rules governing health insurance. These sources can help you understand which ones apply to you and your policy.

The Georgetown University Health Policy Institute has written a guide -- “Consumers Guide for Getting and Keeping Health Insurance” -- to health insurance for each state. The guides are available at www.healthinsuranceinfo.net

The National Assn. of Insurance Commissioners has helpful information on its website at www.naic.org.

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lisa.girion@latimes.com