Between 2018 and 2021, Wilmington, North Carolina resident Stephanie Christy was covered under an individual health plan sponsored by Blue Cross Blue Shield of North Carolina (BCBSNC). Until she wasn’t…and was left with a massive bill because of it.
According to a February 28th article from the Allen Health Academy, Stephanie suffers from severe, chronic migraines and other illnesses. There are times that her migraines are so bad that she is left in bed for days, sensitive to light, smell, and sound, and has difficulty seeing. Her condition is so severe that she is unable to work. Because of this, she was granted disability coverage under Medicare in the summer of 2021.
Medicare also happened to backdate its coverage to 2018. This wouldn’t have been a problem, until BCBSNC considered Medicare to be Stephanie’s primary payer since 2018 (even though it wasn’t). As a result, Blue Cross clawed back the money it paid to Stephanie’s doctors, nutritionist, and physical therapists between 2018 and 2021, which amounted to 273 bills.
Blue Cross’s actions not only left Stephanie’s providers with nothing, but it also left her owing $42,546 in medical bills. The Explanation of Benefits (EOB) of cancelled claims was 32 pages long. So, what happened to the four years of premiums that Stephanie paid to her insurer? Blue Cross kept them. Soon, Stephanie was swimming in notices from collection agencies.
It wasn’t until Stephanie found patient advocate Marilyn Whitley that she was able to find some hope. Marilyn contacted each medical provider to resubmit the bills to Medicare, but not all claims have been paid yet, and it’s estimated that more than $10,000 needs to be reimbursed.
So, how did this happen?
“The insurer said in a statement that its action falls under what insurance companies all ‘Coordination of Benefits,’” according to the article. This means that if a patient has coverage through more than one insurance plan, the benefits from one plan are determined and paid before the second plan’s benefits are determined and paid.
All would be well if Blue Cross actually coordinated with Stephanie over her denied claims. Even though Stephanie had called, Blue Cross did nothing to assist her or to explain to her what was happening. Blue Cross issued a simple, unhelpful apology: “We sincerely apologize that we were not able to provide more education on that date,” the insurer said in a statement.
If Stephanie didn’t have a patient advocate with her, she’d be left in the middle to fend for herself. But patients shouldn’t have to employ third parties to help them navigate the coverage they pay for. Stephanie’s story is just another example of how complicated the insurance system is, and why its complexity often leads to fewer benefits for patients — and more profits for insurers.
