Your EASY guide to the legal system.
News January 23, 2012
Why Health Insurers Don’t Pay and What You Can Do About It Part 4 A Real Life Example: Chapter 2 By: B. Allen Bradford, Esq.
Highslide JS
No Video Available.

This column is primarily for individual consumers, physicians, small businesses and small health care companies. Big hospitals and insurers play a vital role in the American health care system and I have nothing against them.  In fact, I spent 15 years inside the health insurance industry.  But the big players have plenty of very good lawyers to help them already.  My purpose here is to help others better understand how to navigate the health care system, which is sometimes bewildering, even to me. I’ll describe how to exercise your rights, some of the new rules imposed by the 2010 Affordable Care Act and other laws, and other topics that may be of practical value.

In my two June, 2011 posts titled “Why Health Insurers Don’t Pay and What You Can Do About It,” I had promised a future post to describe “an actual, real-life, frustrating and ultimately successful attempt to get health claims paid.”  I began that story in my last post (“A Real Life Example: Chapter 1”), will complete it in this post, and will review lessons learned from our story in Chapter 3, with reference my June posts.




Leon Parker was an employee of Green Circle Health Insurance (“GCHI”), with which he and his family also had health insurance coverage.  Following a horseback riding accident, Leon’s daughter, Cathy, began receiving physical therapy from Chain Physical Therapy (“Chain PT”), which was scheduled to run from October, 2009-March, 2010.  Unfortunately, Leon lost his job effective October 31.  He opted for COBRA coverage with GCHI, but didn’t file until October 29, so Chain PT at first didn’t show Cathy as being an eligible member.  He and his wife, Tina, were surprised to receive a December billing statement stating they owed all the payments due for Chain PT’s services to Cathy in November.  Thinking that the COBRA administrator, GCHI and/or Chain PT just needed a little more time to get their records straightened out, Leon decided not to worry about it.


Leon’s innocent bliss is about to be rudely dispelled!


Getting the Bad News


December, 2009:  Cathy continues to receive services from Chain Physical Therapy.


January 12, 2010: Leon receives a new billing statement from Rehabilitation Management, Inc. for services rendered by Chain PT in October, November and December 2009.  For October and November, this statement shows the same information as the last one.  And for December, it shows payment information similar to October’s with the only balance due from Leon as copayments.   But for November, it still shows a total amount due of $2196.


Now concerned, Leon calls the GCHI customer service number on the back of his health care ID card.   A customer service rep (“Alfonso”) says, “Chain PT didn’t send us claims for November, 2009.  They need to send the claims to us for payment.”  Leon then calls Chain PT, and after waiting on hold for 5 minutes, reaches a customer service rep named “Patty,” to whom he explains the situation.  He adds that, since he worked for an insurance company, he (like those who read my June posts) knows that an insured patient should not be billed by the health care provider for anything other than copayment, coinsurance, deductible, or amounts he specifically agreed to pay for services he knew wouldn’t be covered by insurance. Patty responds that their records show that Cathy was not insured when services were rendered, but that Chain PT did in fact send the invoice to GCHI—she doesn’t understand why Alfonso said they didn’t—but GHCI would not pay, so Chain PT assumed that was because Cathy was not a member.  Patty says she will look into the matter and get back to Leon at a later date.


Leon then does several more things.  He goes to Chain PT’s website, finds a customer service email address, sends an email recounting the problem and his conversation with Patty, and makes a copy for his records.  He also sends a copy of the email by regular mail to the customer service address.  He then forwards the email to GCHI with a cover email explaining that he had discussed the matter with Alfonso.


The Plot Thickens: Enter TherapyNet


January 22, 2010:  The Parkers receive a letter addressed to Cathy from a company called “TherapyNet.”  The letter is long—3 pages in 10-point font!  But the important statements are: “TherapyNet reviews certain physical and occupational therapy requests to determine if they are medically necessary and a covered service under the Green Circle benefit plan.  Chain Physical Therapy has approved the following procedure(s) for Catherine Parker: 6 physical therapy visits.  The approval is valid from 1/23/2101 through 4/09/2010.”


Says Tina to Leon: “What’s this about?”  Leon responds: “GCHI has probably contracted with TherapyNet to manage physical therapy benefits.  That means the insurance company is paying TherapyNet to make sure providers don’t do anything more than necessary to address the patient’s actual needs.  The idea is for Green Circle to save money but with no harm to the patient.”  “What happens if Cathy needs more than 6 treatments?” asks Tina.  “Chain will have to get additional authorization from TherapyNet or not get paid.”


Leon figures they’ll deal with these issues as they come, and thinks nothing further about the matter.  However, he does note that he hasn’t heard yet from Chain PT or GCHI.


Billings Continue and Frustrations Mount


February 8, 2010:  The Parkers receive another billing statement from Rehabilitation Management, still saying that the Parkers owe $2196 for November, although for all services rendered to Cathy after November, “Insurance Payments” have been made and nothing billed to the Parkers, except for some relatively small co-payment amounts.


Leon figures Chain PT and GCHI need more time to work out their payment problem, and decides not to call again.  However, he also decides not to pay the remaining copayments until and unless Chain gets the matter straightened out.


March 9, 2010: The Parkers receive yet another billing statement from Rehabilitation Management, still saying the Parkers owe $2196 for November.


Now frustrated, Leon again calls GCHI.  The customer service rep (“Audrey”) looks up the records, and again says no invoices have been received for Chain PT’s November services, and that if they aren’t sent soon, the time for doing so will expire.  However, now she adds a new wrinkle: “They first need to go to TherapyNet, which has been managing physical therapy benefits for us since November.” She also offers to let Chain PT know what to do.


Leon emails and writes Chain PT, providing his name, his daughter’s name and account ID number, a description of the services and dates of service, and specifically states “I do not understand or agree with the amount on the bill.”  He recounts the past history and conversations with Chain PT and GCHI, including dates of his previous emails and letters. He also asks Chain PT to send the invoice to TherapyNet and offers to get all the parties on the phone to get the matter worked out. He sends copies to GCHI.


He gets no response from anyone.


April 5, 2010:  The Parkers receive still another billing statement showing $2196 owed for November.


Now angry, Leon calls GCHI to ask why this thing hasn’t been settled yet.  He’s routed to “Steven,” who says the records show that Audrey had, indeed, spoken with Chain PT on March 9; that Chain PT had sent a new claim form a week later; but that it didn’t include procedure codes needed for identifying the services rendered, so GCHI sent it back to Chain PT asking for an itemized bill.  Steven gave Leon the claim “number” and a confirmation number for the call for future reference.  Steven said nothing about TherapyNet.


Leon also calls Chain PT again and speaks to “Nora.”  She has an entirely different story from anything Leon has heard before: she says Rehabilitation Management, acting for Chain PT, did send the claim to TherapyNet some time before, but it was denied due to “lack of prior authorization.”  Gritting his teeth, Leon said “that doesn’t mean you get to bill me; you should have gotten the prior authorization, and I know that the terms of your contract say you won’t bill us for anything that’s not a copayment, coinsurance or deductible unless we agree to pay for it in advance.”  Nora did say they’re trying to work out the payment issues with TherapyNet and GCHI, and would look into it further. Leon states that he will pay nothing on the bill, including the copayments that he does owe, until the matter is settled.


He hears nothing until May 21.


May 21, 2010: The Parkers receive another bill for Chain PT, but now it’s a little different.  It still shows all 9 “Charges” for November, but for 5 of them it shows “Insurance Payments” made, with further “Account Adjustments” (or reductions) that result in a “Patient Balance” of about 30% of the total charges.  The other 4 “Patient Balance” charges each remain in the amount of $244.  Now the Parkers are told they owe $1433.40 for November—an improvement from $2196, but still more than Leon thinks is owed—plus the copayments he had been refusing to make.


Now very concerned, frustrated and angry, Leon collects all his records.  He goes to the GCHI website, and using his username and password, accesses all “Claim Details” of all payments made for his family’s health care benefits back to November 1, 2009.  These show that the 4 charges were rejected as “Not Covered” and because “The provider should submit the claim to TherapyNet.”  He emails this information to Chain PT, and follows up with a letter to which he attaches his email.


At Last, Resolution


May 28, 2010: Leon receives a stern letter from Chain PT’s “Pre-Collections Department.”  He is stunned to read “We regret that you have not responded to previous statements concerning your now seriously past due account,” since he had actually responded repeatedly, but had only received continued billing statements.  And in bold letters, he reads “THIS WILL BE YOUR FINAL NOTICE BEFORE YOUR ACCOUNT IS SENT TO A COLLECTION AGENCY.”  And “Please understand that this action may adversely affect your credit rating.”


Convinced that he will get nowhere with Chain PT, Leon contacts GCHI yet again.  He tells “Katie” that he must have this matter resolved once and for all TODAY, because of the threat in the letter and that he will take legal action, if necessary, against GCHI, Chain PT, TherapyNet and Rehabilitation Management to protect his credit rating.  Katie refers him to “Eunice” a “customer support specialist.”  One more time, he explains the matter to Eunice, who pulls up his records, and says “all of those November invoices should have gone to Therapy Net, but apparently none did.  In fact, we shouldn’t have even paid for the 5 claims we covered in November—those should have gone to TherapyNet and nothing should have been billed to you except copayments.”  “That’s what I’ve been saying all along.” says Leon in exasperation.  “PLEASE contact Chain PT while I’m on the phone and talk to someone who will listen.  I’ll stay on as long as it takes. Enough is enough!”  Unfortunately, Eunice was ultimately forwarded to Chain PT’s billing office—and got a recording explaining “No one is available at this time” (!!). Eunice left a message and promised to call Leon with the results the next day.


For once, a customer service rep does as promised.  Eunice calls the next day to say “It’s all taken care of.  All you need to do is pay the copayments and you won’t hear from Chain PT or Rehabilitation Management again.”  “Can I get an email copied to Chain PT saying that?” asks Leon?  “Yes,” says Eunice.  When Leon receives the email later that day, he pays the balance—and does not hear from Chain PT or Rehabilitation Management again!




Some time later, Leon, now working for a different company and with a new health plan, runs into a former colleague from Green Circle at a coffee shop.  After some small talk, remembering that the former colleague was a manager in Green Circle’s operations department, Leon briefly mentions the frustrating experiences with Cathy’s physical therapy treatment payments.  “Oh, God, I know where you’re going with this,” says the former colleague.  “I worked on implementing our contract with TherapyNet.  There was total confusion between them, us and the physical therapists.  It took months to get that thing straightened out.  It was chaos!”  At this point, Leon just laughs--but it confirms what he had suspected all along; there was no evil intent by anyone involved—just frustrating operating confusion by everyone involved!




We review some “lessons learned” and apply pointers from my June posts on “Why Health Insurers Don’t Pay and What You Can Do About It.”

B. Allen Bradford