11 June 2014


Original Story: Chicago Tribune

Just days after Bernita Klokner's family moved her from Florida back to the Midwest last May, the 97-year-old fell and broke her hip.

After the ensuing surgery, Klokner was moved from a hospital in Milwaukee to a nearby rehabilitation center.

The ambulance company charged her $585.70 for the ride, but neither she nor her family was particularly worried. They submitted the claim to WellCare, the health insurance company administering her Medicare plan.

They had no idea there would be any trouble until they got a denial letter in July.

The letter informed Klokner that WellCare would not pay for the ride because she had not submitted proof that the ambulance company had gotten prior authorization.

Klokner's daughter, Sharon Reich, of Grayslake, was stunned. Reich, a registered nurse, said she has filled out similar forms many times for her patients.

She promptly requested, and received, the proper paperwork from her mother's doctor and, in early September, filed an appeal.

Ten days later, WellCare wrote back saying it would not consider the appeal because Reich wasn't authorized to represent her mother.

In late September, Reich sent paperwork proving she legally represents her mother. WellCare again dismissed the appeal in November, stating it had not gotten Reich's documents.

Reich said she called WellCare in December, and a representative told her she had found Reich's paperwork. The representative said the insurance company would reconsider paying the $585.70.

Months passed and Reich heard nothing. When she called, she was promised a return call within days. No one called back, Reich said.

By May, Reich still hadn't heard whether WellCare would pay the ambulance bill, and she was beginning to worry all hope was lost. She tried calling the insurance company again, but phone lines were jammed, she said.

"I can't get through on the 800 number," she said. "I call and you get these prompts. I go through the prompts. You get a recording. The phone rings 53 times, and then it hangs up."

Undaunted, Reich began calling WellCare's corporate headquarters. She had two brief conversations, then was disconnected both times, she said.

"Every time I call, there's a different reason why they're not paying it," she said. "I don't know what to do."

Tired of fighting a seemingly unwinnable battle with WellCare, Reich emailed "What's Your Problem?" in mid-May.

She said the ambulance company has been patient, but it has been more than a year.

"It's expensive," she said of the $585.70. "In short, this claim should be paid."

The Problem Solver called WellCare and explained the situation.

On Wednesday, WellCare spokeswoman Crystal Warwell Walker emailed with good news.

Walker said that although emergency health services do not require prior authorization, WellCare does require such authorization for some nonemergency services, such as ambulance transportation.

"When a pre-authorization is not obtained before a service is delivered, a claim may be denied," Walker wrote.

Members can appeal by providing proof of authorization, she said. Also, representatives wishing to address a matter on behalf of a member must provide proper paperwork, Walker said.

"Any time the processes and associated deadlines are not followed, a claim cannot be approved per the protocols," Walker said.

But after examining Klokner's case, the insurance company decided to overturn its initial decision.

"WellCare understands that there can be cases where protocols are followed, but the outcomes are not in line with a provider's intent and the member's health care needs," Walker said. "In this specific case, the matter has been reviewed and WellCare will pay the claim due to the unique circumstances."

Reich was shocked. She said her mother, now 98, could never have fought WellCare on her own.

"I don't know if an older person who qualifies for Medicare like my mother can deal with these people," Reich said. "They would just give up."

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