Health insurer tries to avoid owning up to error

Who should pay when a health insurer screws up? Not the insurer, apparently.

Seal Beach resident Kelley Barton wanted to be sure that a treatment would be approved by Anthem Blue Cross when she sought medical care last year for her 14-year-old son, who had suffered from chronic constipation since he was a little boy.

"I wouldn't even schedule the procedure until I knew it was covered," Barton, 51, told me. "I knew it probably wouldn't be cheap, and I didn't want to have to fight about it with my insurance company."

The procedure in question was a biofeedback technique involving sensors and muscle training to help Barton's son. Studies have shown that biofeedback is an effective remedy for chronic constipation.

But Barton wasn't taking any chances.

She asked her doctor's staff to contact Anthem and confirm that the treatment would be covered. They were told that, yes, this approach for this particular condition was acceptable to the insurer's bean counters.

Just to make sure, Barton said, she called Anthem herself. She wanted to hear it firsthand: Was the treatment covered by her family's insurance policy, for which they paid more than $1,000 a month in premiums, co-pays and deductibles?

No problem, Barton said an Anthem rep told her. You're covered.

So Barton's son made three trips to Children's Hospital of Orange County.

And guess what? Barton ended up fighting with Anthem over a treatment that the insurer now says was "investigative" or "not medically necessary" and thus not covered.

No, wait. Anthem did cover the third of the boy's three hospital visits. It rejected the first two, even though each visit involved the exact same procedure.

Even more perplexing, Barton said the company conceded that its customer reps made a mistake in saying that the treatment was approved -- not once but twice -- but it nevertheless denied her appeal and demanded that it be paid in full for the two outstanding treatments.

The bill: about $1,600.

Anthem told Barton that it wouldn't go after her. Instead, it went after the hospital.

The hospital, in turn, sent Barton a bill for the full cost of the treatment, leaving her vulnerable to a hit on her credit score if she didn't come up with some cash.