Worst Claim Story— December 2018

Jackie Koontz, AE, Kaizen Coach

Appeal letter for crown and build-up:

To Whom It May Concern:

I am writing to you to today to express my deep concerns over the gross mishandling of Dewayne’s claim for #31 crown and buildup and wrongful denial. On 4/18/18 our office sent Dewayne’s claim electronically with all necessary attachments and a narrative. On 5/10/18 we received a notice from Metlife stating there was insufficient evidence provided to support the need for treatment. Again, we submitted Dewayne’s claim with sufficient attachments and narratives to process his claim (see attached xrays, chart notes, and claim form). On 6/6/18, our office was able to check on Dewayne’s claim online and his claim was denied once again. This time the reasoning being: “The attachment number submitted was either invalid or was a valid attachment number for a different payor. Please re-submit this claim with a valid attachment number for MetLife.” The NEA number 139689266 was indeed sent with Dewayne’s claim through our clearinghouse and was sent at the same time as his claim. I firmly believe this excuse to be another delay tactic to either wear us down and give up on receiving payment, or to generally be obnoxious. I’m assuming it’s the former.  

The situation with this claim came to a head on 6/6/18 when I called Metlife to clear up the confusion on the submitted NEA. I called and talked with a rep named Sol. After giving her the NEA number again she then changed the denial reason to state that the procedures were denied due to Metlife not covering crowns and buildups completed on the same date of service. I tried to explain about CEREC crowns and how I had never previously heard of this Metlife policy, only to be met with open hostility and indifference.  I pressed further, stating that I did not believe she would be able to assist me and that I insisted to speak with her superior. Sol put me on hold in silence and refused to respond to my questions for an update for a supervisor. After 20 minutes on hold, I realized Sol had no intentions of transferring me. I immediately called back through Metlife’s automated system and went through the normal prompts to get through to another rep in the hopes of a resolution. The automated system did not transfer me and instead said “please wait” for approximately 10 minutes. I can only assume that Sol somehow internally flagged our TIN or my phone number in order to undermine me further.

Regrettably, the situation described in the paragraph above is not only typical of an experience with Metlife, but almost expected. Metlife reps are untrained, speak from only a script, and have no tools nor are they willing to help resolve claim issues. Attachments and claims are regularly not received by Metlife from all different clearinghouses–why?. Providers do not have the tools available via Metlife’s website or automated system to resolve issues, leaving the only option being hostile  “customer service” representatives whose only intentions are to get you off of the phone as fast as possible. I say this with the experience of a office manager that has worked with multiple offices over 11 years with the same consistent experience with this company. How have they been allowed to operate and function in such a manner for so long? Why? This appeal letter is one not only geared to Dewayne, but the countless others affected by Metlife’s delay tactics and wrongful denials. My heart aches for all those patients who do not have an advocate in an office willing to fight for every dollar that is rightfully owed to their claims and treatment provided.  

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