Our insurance industry is such a scam and I hate it.
I've learned so much since becoming a medical biller and it is sickening
how intentionally complicated the system is. You can NOT trust
anything your insurance tells you unless it is in writing. Only in writing
is valid and can be argued. But even then compare what they give you in writing
to what you SIGNED UP FOR BECAUSE THEY DON'T KNOW HOW THEIR OWN SYSTEM WORKS.
(I'M SERIOUS)

I did an experiment this week (which we already knew the results but had to prove it.)
Thankfully my patient has a spitfire personality and was willing to help me do this.

"Patient" Calls insurance customer line, and is told she has 100% full coverage. Patient specifies "at this clinic?"
and the insurance lady on the phone LITERALLY says "Yes, you have 100% full coverage for all services
at their clinic- I am not sure why they are telling you otherwise. You have unlimited visits" I was in the room, that person was on speaker phone.
I recorded this call (with patient permission.)

Immediately as they hung up, I called the provider line (I am not allowed to call customer line, just as the patient
is not allowed to call provider line.) Again I am recording. I give the patient's full info and ask for coverage.
The person on the phone tells me that patient is out of visits for this year and has to pay out of pocket.
I inform them they told the patient that she has unlimited visits. The man I spoke with on the phone (again, I'm recording and
the patient is sitting with me.) says she is lying/severely misunderstanding. My patient raises a brow at me like
"oh no they didn't *zsnap*"

I hang up. I ask the patient to get a fax of her benefits plan (I show her how.)
The fax comes through. She has 100% unlimited coverage so long as it is medically necessary.
I call back and ask them to define medically necessary. They say "Has a pain diagnoses from an MD"
check. she has that. "So she should have full coverage according to her benefits plan." "Yes"
"So I can treat her and you guys will pay the claims you rejected?" "No" "Why?" "she is out of visits."

Patient calls back the customer line. Lady says "Yes this provider has called us several times this morning
according to the notes, I don't know why they are making this so hard for you." I laugh out loud, patient does too.

I ask to speak with a manager. They hung up on me.

I call back. 30 minute wait, patient leaves I have permission to show recordings.
(on the recordings is the patient verbally consenting me to record)
I play them for the higher up. They ask me why I am playing games.
What games??????? YOU ARE TELLING US TWO DIFFERENT THINGS AND TRYING TO
GET HER MAD AT ME BECAUSE YOU CANT FOLLOW YOUR OWN POLICY.

"Well don't you think 20 visits a year is a enough?"
"If she has unlimited, she is entitled to unlimited and that is not up to your opinion. You are
not a medical professional. You have to follow the written terms you can't just make it up on
your own, that's ILLEGAL. She PAYS for a plan, that you both agreed to, and YOU are restricting her and
then lying about it. I wait for a response and get none.

I file the recordings to the state of Massachusetts and within an hour hear back from the insurance
"Sorry for the misunderstanding. Sometimes paper work gets mixed up. You're all set, we'll cover those
denied claims."

PEOPLE! If you are reading this. DON'T let your insurance bum you outta something they are CONTRACTED to
provide. They absolutely rely on you to be gullible and will scam you out of services you have a right to. (happens literally daily at my job)
providers will also be shitty and over charge your insurance not caring if it uses up some of your benefits and makes you pay higher
out of pocket. It's a pain in the ass but if you have a limited insurance always always ask for a copy of bills from doctors.
it is your LEGAL RIGHT to see them don't let ANYONE tell you otherwise.

*breathes fire*