This story is not practical advice. For me, it’s closing the book on an almost two-year saga. For you, I hope it’s an enjoyable bit of bureaucratic schadenfreude. For Anthem, I hope it’s the subject of a series of painful but transformative meetings. This is not an isolated event. I’ve had dozens of struggles with Anthem customer support, and they all go like this.
If you’re looking for practical advice: it’s this. Be polite. Document everything. Keep a log. Follow the claims process. Check the laws regarding insurance claims in your state. If you pass the legally-mandated deadline for your claim, call customer service. Do not allow them to waste a year of your life, or force you to resubmit your claim from scratch. Initiate a complaint with your state regulators, and escalate directly to Gail Boudreaux’s team–or whoever Anthem’s current CEO is.
To start, experience an equipment failure.
Use your CPAP daily for six years. Wake up on day zero with it making a terrible sound. Discover that the pump assembly is failing. Inquire with Anthem Ohio, your health insurer, about how to have it repaired. Allow them to refer you to a list of local durable medical equipment providers. Start calling down the list. Discover half the list are companies like hair salons. Eventually reach a company in your metro which services CPAPs. Discover they will not repair broken equipment unless a doctor tells them to.
Leave a message with your primary care physician. Call the original sleep center that provided your CPAP. Discover they can’t help, since you’re no longer in the same state. Return to your primary, who can’t help either, because he had nothing to do with your prescription. Put the sleep center and your primary in touch, and ask them to talk.
On day six, call your primary to check in. He’s received a copy of your sleep records, and has forwarded them to a local sleep center you haven’t heard of. They, in turn, will talk to Anthem for you.
On day 34, receive an approval letter labeled “confirmation of medical necessity” from Anthem, directed towards the durable medical equipment company. Call that company and confirm you’re waitlisted for a new CPAP. They are not repairable. Begin using your partner’s old CPAP, which is not the right class of device, but at least it helps.
Over the next 233 days, call that medical equipment company regularly. Every time, inquire whether there’s been any progress, and hear “we’re still out of stock”. Ask them you what the manufacturer backlog might be, how many people are ahead of you in line, how many CPAPs they do receive per month, or whether anyone has ever received an actual device from them. They won’t answer any questions. Realize they are never going to help you.
On day 267, realize there is no manufacturer delay. The exact machine you need is in stock on CPAP.com. Check to make sure there’s a claims process for getting reimbursed by Anthem. Pay over three thousand dollars for it. When it arrives, enjoy being able to breathe again.
On day 282, follow CPAP.com’s documentation to file a claim with Anthem online. Include your prescription, receipt, shipping information, and the confirmation of medical necessity Anthem sent you.
On day 309, open the mail to discover a mysterious letter from Anthem. They’ve received your appeal. You do not recall appealing anything. There is no information about what might have been appealed, but something will happen within 30-60 days. There is nothing about your claim.
On day 418, emerge from a haze of lead, asbestos, leaks, and a host of other home-related nightmares; remember Anthem still hasn’t said anything about your claim. Discover your claim no longer appears on Anthem’s web site. Call Anthem customer service. They have no record of your claim either. Ask about the appeal letter you received. Listen, gobsmacked, as they explain that they decided your claim was in fact an appeal, and transferred it immediately to the appeals department. The appeals department examined the appeal and looked for the claim it was appealing. Finding none, they decided the appeal was moot, and rejected it. At no point did anyone inform you of this. Explain to Anthem’s agent that you filed a claim online, not an appeal. At their instruction, resign yourself to filing the entire claim again, this time using a form via physical mail. Include a detailed letter explaining the above.
On day 499, retreat from the battle against home entropy to call Anthem again. Experience a sense of growing dread as the customer service agent is completely unable to locate either of your claims. After a prolonged conversation, she finds it using a different tool. There is no record of the claim from day 418. There was a claim submitted on day 282. Because the claim does not appear in her system, there is no claim. Experience the cognitive equivalent of the Poltergeist hallway shot as the agent tells you “Our members are not eligible for charges for claim submission”.
Hear the sentence “There is a claim”. Hear the sentence “There is no claim”. Write these down in the detailed log you’ve been keeping of this unfurling Kafkaesque debacle. Ask again if there is anyone else who can help. There is no manager you can speak to. There is no tier II support. “I’m the only one you can talk to,” she says. Write that down.
Call CPAP.com, which has a help line staffed by caring humans. Explain that contrary to their documentation, Anthem now says members cannot file claims for equipment directly. Ask if they are the provider. Discover the provider for the claim is probably your primary care physician, who has no idea this is happening. Leave a message with him anyway. Leave a plaintive message with your original sleep center for good measure.
On day 502, call your sleep center again. They don’t submit claims to insurance, but they confirm that some people do successfully submit claims to Anthem using the process you’ve been trying. They confirm that Anthem is, in fact, hot garbage. Call your primary, send them everything you have, and ask if they can file a claim for you.
On day 541, receive a letter from Anthem, responding to your inquiry. You weren’t aware you filed one.
Please be informed that we have received your concern. Upon review we have noticed that there is no claim billed for the date of service mentioned in the submitted documents, Please provide us with a valid claim. If not submitted,provide us with a valid claim iamge to process your claim further.
Stare at the letter, typos and all. Contemplate your insignificance in the face of the vast and uncaring universe that is Anthem.
On day 559, steel your resolve and call Anthem again. Wait as this representative, too, digs for evidence of a claim. Listen with delight as she finds your documents from day 282. Confirm that yes, a claim definitely exists. Have her repeat that so you can write it down. Confirm that the previous agent was lying: members can submit claims. At her instruction, fill out the claim form a third time. Write a detailed letter, this time with a Document Control Number (DCN). Submit the entire package via registered mail. Wait for USPS to confirm delivery eight days later.
On day 588, having received no response, call Anthem again. Explain yourself. You’re getting good at this. Let the agent find a reference number for an appeal, but not the claim. Incant the magic DCN, which unlocks your original claim. “I was able to confirm that this was a claim submitted form for a member,” he says. He sees your claim form, your receipts, your confirmation of medical necessity. However: “We still don’t have the claim”.
Wait for him to try system after system. Eventually he confirms what you heard on day 418: the claims department transferred your claims to appeals. “Actually this is not an appeal, but it was denied as an appeal.” Agree as he decides to submit your claim manually again, with the help of his supervisor. Write down the call ref number: he promises you’ll receive an email confirmation, and an Explanation of Benefits in 30-40 business days.
“I can assure you this is the last time you are going to call us regarding this.”
While waiting for this process, recall insurance is a regulated industry. Check the Ohio Revised Code. Realize that section 3901.381 establishes deadlines for health insurers to respond to claims. They should have paid or denied each of your claims within 30 days–45 if supporting documentation was required. Leave a message with the Ohio Department of Insurance’s Market Conduct Division. File an insurance complaint with ODI as well.
Grimly wait as no confirmation email arrives.
On day 602, open an email from Anthem. They are “able to put the claim in the system and currenty on processed [sic] to be applied”. They’re asking for more time. Realize that Anthem is well past the 30-day deadline under the Ohio Revised Code for all three iterations of your claim.
On day 607, call Anthem again. The representative explains that the claim will be received and processed as of your benefits. She asks you to allow 30-45 days from today. Quote section 3901.381 to her. She promises to expedite the request; it should be addressed within 72 business hours. Like previous agents, she promises to call you back. Nod, knowing she won’t.
On day 610, email the Ohio Department of Insurance to explain that Anthem has found entirely new ways to avoid paying their claims on time. It’s been 72 hours without a callback; call Anthem again. She says “You submitted a claim and it was received” on day 282. She says the claim was expedited. Ask about the status of that expedited resolution. “Because on your plan we still haven’t received any claims,” she explains. Wonder if you’re having a stroke.
Explain that it has been 328 days since you submitted your claim, and ask what is going on. She says that since the first page of your mailed claim was a letter, that might have caused it to be processed as an appeal. Remind yourself Anthem told you to enclose that letter. Wait as she attempts to refer you to the subrogation department, until eventually she gives up: the subrogation department doesn’t want to help.
Call the subrogation department yourself. Allow Anthem’s representative to induce in you a period of brief aphasia. She wants to call a billing provider. Try to explain there is none: you purchased the machine yourself. She wants to refer you to collections. Wonder why on earth Anthem would want money from you. Write down “I literally can’t understand what she thinks is going on” in your log. Someone named Adrian will call you by tomorrow.
Contemplate alternative maneuvers. Go on a deep Google dive, searching for increasingly obscure phrases gleaned from Anthem’s bureaucracy. Trawl through internal training PDFs for Anthem’s ethics and compliance procedures. Call their compliance hotline: maybe someone cares about the law. It’s a third-party call center for Elevance Health. Fail to realize this is another name for Anthem. Begin drawing a map of Anthem’s corporate structure.
From a combination of publicly-available internal slide decks, LinkedIn, and obscure HR databases, discover the name, email, and phone number of Anthem’s Chief Compliance Officer. Call her, but get derailed by an internal directory that requires a 10-digit extension. Try the usual tricks with automated phone systems. No dice.
Receive a call from an Anthem agent. Ask her what happened to “72 hours”. She says there’s been no response from the adjustments team. She doesn’t know when a response will come. There’s no one available to talk to. Agree to speak to another representative tomorrow. It doesn’t matter: they’ll never call you.
Do more digging. Guess the CEO’s email from what you can glean of Anthem’s account naming scheme. Write her an email with a short executive summary and a detailed account of the endlessly-unfolding Boschian hellscape in which her company has entrapped you. A few hours later, receive an acknowledgement from an executive concierge at Elevance (Anthem). It’s polite, formal, and syntactically coherent. She promises to look into things. Smile. Maybe this will work.
On day 617, receive a call from the executive concierge. 355 days after submission, she’s identified a problem with your claim. CPAP.com provided you with an invoice with a single line item (the CPAP) and two associated billing codes (a CPAP and humidifier). Explain that they are integrated components of a single machine. She understands, but insists you need a receipt with multiple line items for them anyway. Anthem has called CPAP.com, but they can’t discuss an invoice unless you call them. Explain you’ll call them right now.
Call CPAP.com. Their customer support continues to be excellent. Confirm that it is literally impossible to separate the CPAP and humidifier, or to produce an invoice with two line items for a single item. Nod as they ask what the hell Anthem is doing. Recall that this is the exact same machine Anthem covered for you eight years ago. Start a joint call with the CPAP.com representative and Anthem’s concierge. Explain the situation to her voicemail.
On day 623, receive a letter from ODI. Anthem has told ODI this was a problem with the billing codes, and ODI does not intervene in billing code issues. They have, however, initiated a secretive second investigation. There is no way to contact the second investigator.
Write a detailed email to the concierge and ODI explaining that it took over three hundred days for Anthem to inform you of this purported billing code issue. Explain again that it is a single device. Emphasize that Anthem has been handling claims for this device for roughly a decade.
Wait. On day 636, receive a letter from Anthem’s appeals department. They’ve received your request for an appeal. You never filed one. They want your doctor or facility to provide additional information to Carelon Medical Benefits Management. You have never heard of Carelon. There is no explanation of how to reach Carelon, or what information they might require. The letter concludes: “There is currently no authorization on file for the services rendered.” You need to seek authorization from a department called “Utilization Management”.
Call the executive concierge again. Leave a voicemail asking what on earth is going on.
On day 637, receive an email: she’s looking into it.
On day 644, Anthem calls you. It’s a new agent who is immensely polite. Someone you’ve never heard of was asked to work on another project, so she’s taking over your case. She has no updates yet, but promises to keep in touch.
She does so. On day 653, she informs you Anthem will pay your claim in full. On day 659, she provides a check number. On day 666, the check arrives.
Deposit the check. Write a thank you email to the ODI and Anthem’s concierge. Write this, too, down in your log.