169 Minutes Navigating Health Care

There has been a lot of public attention lately to how angry consumers are about their health care. As someone who lives with a chronic health condition, I interface with the system often and as a health policy expert who understands the nuts and bolts of how the system should work, you would think that I could more easily navigate my care than most. But guess what, even as someone with over 25 years in the business, I often face immense hurdles.

Last Friday I spent nearly 3 hours trying to get this simple question answered: Will my Blue Cross Blue Shield Federal Employees Program (FEP) benefits cover my participation in the Mayo Chronic Pain Rehabilitation (CPR) program? Sounds like an easy one to answer, right?

A little background on Mayo’s CPR program: This is an intensive 3-week outpatient program that is multi-modal, which means they provide both physical and mental health services to those with persistent chronic pain including: group counseling, physical therapy, occupational therapy, and other related services. This type of pain care has been proven to be very successful at treating the biopsychosocial nature of pain. If you want to learn more about the program, check out their website HERE.

I already had a one-hour intake call with Mayo and have been accepted to the program from a clinical perspective. You see, I’ve lived with daily chronic pain for 10 years and have exhausted all other interventions including three surgeries, medications, physical therapy, individual pain counseling, and other measures. So when the nurse said I’m a great candidate I thought, great, I’m all in. The nurse tells me we just need the Mayo pre-certification department to talk to my insurance and then we can move to scheduling.

I was very optimistic and hopeful that this would go smoothly. I’m lucky to have some of the best health insurance in the country given my spouse is a federal employee and FEP benefits are pretty robust. So with optimism, I connect with Mayo last Friday and my experience goes like this:

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11:38 AM Mayo. 5 minutes.

I speak with Mayo’s pre-certification department. They indicate that they have contacted Blue Cross Blue Shield Federal Employees Program (BCBS FEP) and that the group therapy services (and essential component of the CPR program) aren’t covered. I ask why? I’m told, because Mayo is billing the services through the medical benefit, not the behavioral health benefit, BCBS FEP says they will not cover this part of the program. Huh? This explanation is confusing to me. You see, we have rules in the U.S. that require that there is parity between physical and mental health services. I’m also pretty sure my benefit includes group counseling (more on this later). The Mayo person says I need to call my health plan, give them this 9-digit reference number she received regarding her call with BCBS and they can explain why the two specific payment codes for group therapy are not covered. Ok. Hang up.

11:51 AM BCBS FEP (CO). 36 minutes.

I’m in Colorado and while the BCBS FEP program is national engaging a web of Blue Cross Blue Shield plans across the country, I hold an insurance card for the Colorado BCBS plan, who administers FEP benefits for people living in the state. So I call the number on my card. I am on hold awhile, explain to the first person I speak to what is happening and that I simply need to understand why Mayo says the services for group counseling are not covered. The woman puts me on hold for a bit, comes back and says “we have no record of a call from Mayo, we don’t even have 9-digit reference numbers”, telling me that their reference numbers have 14 digits. She says I need to call Mayo back. OK. Fine.

12:29 PM Mayo. 2 minutes.

I call Mayo. Quickly explain what I need. The person answering the phone says I need to talk to the same person I spoke with earlier. They direct me to another number. UGH.

12:48 PM Mayo. 10 minutes.

Person from the first Mayo call says that I need to call the BCBS FEP number in Minnesota. Ummm. OK, can you please give me the number? I do not have it as I am a BCBS FEP Colorado member. AND, why did you not tell me this the first time? I think to myself, I’ve lost an hour of my life already, starting to get frustrated. She gives me the number and the two codes for group therapy that she says they were told that were not covered. I feel my stress building and as I hang up and tell myself to try and breathe.

12:51 PM Mayo. Via email.

I receive an email from the Mayo portal. I follow the link, log in to my patient account and see there is a letter from them showing the estimated costs out of pocket for the program that they’ve indicated BCBS FEP will not cover - $53,000 dollars, for the group counseling portion only. I am in utter shock. This is an outpatient program with 10 hours of group counseling a week for three weeks which at that price equates to $1766 dollars per one hour group counseling session. WOW and WTF.

1:02 PM BCBS FEP (MN). 24 minutes.

I call the number Mayo provided for BCBS FEP in Minnesota. I explain to customer service the situation. I give them the codes that Mayo says aren’t covered (for group therapy – 96164 and 96165). They check my benefits and state that they ARE indeed covered services and do not even require a pre-authorization. I explain that I’ve been told by Mayo that they are not covered because they are billing it “through medical”, which I am still not clear on what this means. Customer service tells me that this does not matter and that Mayo is wrong. They put me on hold and call Mayo to explain. I hold and wait. They come back and say, “it should be fine now, I told them its covered.” Ok, thank you. I am thinking though that it cannot be this easy.

1:16 PM My research.

Before I talk to Mayo again and I need to make sure I more fully understand my benefits. I ask my husband Art to send me the BCBS FEP benefits handbook. I open the 172 page PDF document and search for group therapy. Section 5(e) for Mental Health benefits includes group therapy. Ok, BCBS FEP told Mayo it is covered, and my handbook says so. Maybe I’m now on the right track (ha ha, nope). I call Mayo AGAIN.

1:26 PM. Mayo. 8 minutes.

I call the main line that is responsible for the pain program and explain the situation for the 100th time, telling them that BCBS FEP says these services ARE covered. I ask for a manager, someone who can really help me get to the bottom of this and explain that I am very frustrated. They put me on hold while they try to get the original person handling my authorization (which the health plan says is not even required). I’m told to call ANOTHER NUMBER!

1:34 PM. Much needed break.

For the next hour I try to breathe, eat some lunch, brief Art on what I’ve learned so far. I can feel my heart racing and frustration building. It is like I am in a bad dream. I try to calm myself before making my next call.

2:28 PM Mayo. 11 minutes.

I get connect to the person handling my “pre-auth” (again which BCBS says I DO NOT NEED). She tells me that BCBS FEP customer services is wrong, that these group therapy services are not covered saying again that it is because they are billing “through medical”. I say, please explain to me what the that means? I have the benefits and BCBS says it does not matter. I tell the person that I am looking at my policy, including the exclusions section (page 136) which does not say anything remotely close to what she is telling me.

She says that sometimes these exclusions are not included in any written policy. What? So how is a consumer supposed to understand? BCBS FEP is telling me it is covered, you are telling me it isn’t and you have in the meantime sent me a $53K estimate. She says that “group therapy exclusions for medical services outranks plan exclusions”. HUH? If blood could boil mine would right now. My head spins as I think about how to problem solve.

I ask her if we can call BCBS FEP together and try to sort out why I’m being told two different things? She says, ‘no’, this isn’t allowed. Health plan members cannot be on calls with the health plan and the provider. She tells me to ask a supervisor at BCBS FEP customer service to request that they listen to the recording of the Mayo/BCBS call and then they can relay the information regarding non-coverage to me. Wow that is pretty inefficient but I say, OKAY. FINE. She says the services for the pain program used to be covered “through medical” before and no longer are. I keep asking but she cannot seem to explain what “through medical” means but I know that something somewhere is fishy and I am not gonna stop until I get real answers.

2:41 PM BCBS FEP (MN). 1 hour and 13 minutes. (YES, you read that correctly).

I’m emotionally spent at this point but I take a deep breath and pick up the phone and call BCBS FEP again. I explain to customer service the situation and specifically ask for a supervisor. I wait and wait for said supervisor. Once connected, the supervisor listens closely and carefully. I feel like I am finally starting to be heard. I say I need resolution and that I need someone to listen to the damn recording between the plan and Mayo so I can understand what Mayo was exactly told by BCBS FEP. I tell her that my benefit should be covering the services per the earlier feedback I received. She says she sees the call in the system but no written record that the plan told Mayo that the services were not going to be covered. She indicates though that there are circumstances where what shows as a benefit might still indeed be excluded. This seems like a serious transparency issue but I’ll worry about that problem later.

I politely insist that she just please listen to the recording? OK she says, but it takes up to 48 hours to put in the request from customer services to the provider service side to get access to said recording and listen, then follow up with me. Someone will call me back next week. More inefficieny but OK. At least someone is trying to get me answers.

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And that is my 169 minutes of chaos, confusion, and unanswered questions which has led to even more questions. Will I get some sort of resolution? Yes, eventually, because I’m not letting this go because it is just too important. Health care is complex and challenging and some of it is hard to undo. But it can be better. Let’s do better.

Thanks for subscribing to Chronic Pain Chats. Have you had a challenging and complex experience like this one when engaging the health care system? If yes, please share!