Health Care Telephone Representative Tactics

The Centers for Medicare and Medicaid Services buys the health care services for beneficiaries and has oversight responsibility for these programs and takes enforcement actions as appropriate according to the Health Insurance Portability and Accountability Act of 1996. This article is a compelling health care coverage story that shares specific insurance information and negotiation tips that may help others in similar situations.

In 2002, Doctor Baughman said, "United Healthcare has been engaged in corrupt practices in the US: the company was fined $7 million within the last two years for cheating US taxpayers, doctors and patients in nine states." as reported by AHRP.

The number one way to protect yourself is to thoroughly read, highlight and bookmark your paper version of the insurance documents you have. Knowledge is power.

In 2006, the additional coverage called part D provided by United Healthcare's Enhanced Medicare or Medicare Advantage plan is to provide more benefits than the original Medicare plan of part A and B. The online interactive programs wasn't working for months for the state I lived in, (Hawai'i), but when I couldn't obtain a paper copy of the policy without printing out the pdf myself, that's when I came to the realization of the adversarial nature of obtaining coverage from UnitedHealthcare's Evercare insurance.

I had to assert repeatedly for a paper policy that outlines my basic protections. I was mailed a 2005 Evidence of Coverage, (EOC), in February 2006. A 2006 paper was automatically mailed to me months later. As the New Year 2007 arrived, I had extremely low confidence in Evercare's willingness to fulfill evidence of coverage obligations because of their unenthusiastic record in 2006.

The following is my personal story of how it took me two days and many phone calls to get what I wanted, a female Obstetrician/Gynecologist (OB/GYN) in a capital city Honolulu of nearly a million people. Evercare told me that Holzman at Kalihi-Palama Health Center, (KPHC), is not in the network. Rediger is, Navickes is, Batacan is, but not the OB/GYN Holzman.

4/11/2007 - Called Evercare @ 1-866-622-8054 to get a female OB/GYN doctor that is within the Evercare network. No female doctors available and was given two male OB/GYN's, Sato and Ward.
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4/12/2007 - Called Sato = no see Evercare insurance except for ultrasound only at Queen's. Called Ward = not a practicing doctor and does not see patients, administrative head only. I called Never-Evercare and said there is no OB/GYN doctor in my area and that I am seeking prior authorization for Holzman to be covered as if "in net" because there is no available doctor. Evercare answer is NO and even if it was "yes" it wouldn't be a guarantee of coverage - but that I could always appeal.

I asserted right to have according to Evidence of Coverage and Evercare's answer was "where does it say that?" I commented that a person should not have to fight so hard for benefits. The same Evercare representative within the same phone call, then looks up "internal database" and gives me three more names, Tokairian, Rehall, and Alvarez, that were not available to me from the previous two telephone calls during the past two days.

Two of the OB/GYN's are female, which is what I wanted in the first place - but only after a extremely dogged persistence effort on my part. I am grateful that it was not an emergency and that I have the pleasure of having time on my side.

Afterwards, I found the section that I was referring to after the telephone call. It is unreasonable to expect a customer to go through two hours of telephone calls just to get the correct information. The section I was referring to was section 5.B.3. Approved covered health service provided by non-contracted Providers at the preferred benefit level.

As of August 2007, there are now over a hundred OB/Gynecologist MD's listed on the now working, interactive program at Evercare's website. The two names given to me in April 2007 are still on the very short listed under, Obstetrics/Gynecology.

Tip of the Day: Completely study your paper health care insurance documents, such as Evidence of Coverage in order to protect yourself.

Yellow highlight this section and put a tab on the page for easy reference later because you will be tested for this later by the malfeasance of willful ignorance by the corporate representative on the phone who will attempt to deny your entitlements with repeated assertations that's "it's your choice" to go to an Uncovered Healthcare Provider..

This company profits on the fact that you have 'chosen' to go to an out of network health care provider that is not covered by Evercare insurance by not providing you reliable information on who is an Covered provider.

2007 Evidence of coverage for the Evercare Plan DP-ES Medicare Advantage and Medicare Part D Drug coverage H5424, Plan 005 for Honolulu, on page 25 Section 5.B.3 Approved Covered Health Services Provided by Non-Contracted Providers at the Preferred Benefit Level states the following.

"In the event that specific Covered Health Service cannot be provided by a Contracted Physician or other Contracted provider, you may obtain those Covered Health Service from a non-contracted provider, you may obtain those Covered Health Service from s non-Contracted Physician or other non-Contracted provider at the at the Preferred Benefit level with prior approval (italics mine), from us or a member of you Primary Care Team. "

Prior approval is required in this sentence, but the trick is to get the representative to give you the correct information.

It appears that United Healthcare's Evercare has failed to comply with federal contract obligations to provide health coverage in a good faith effort with reasonable business practices by defrauding the beneficiary the freedom to choose a Contracted Physician through feigned incompetence.

The number one way to protect yourself is to thoroughly read, highlight and bookmark your paper version of the insurance documents you have. Knowledge is power. It is difficult to read in one shot and recommend planning about a week to read it. The obtrusive jargon swirls into a jumbled mass of words rather quickly and I do not advise reading more than ten minutes at a time.