Update: on October 21 I received a call from an assistant to CEO Eric Schultz letting me know that they had received my letter and would provide coverage. Apparently they still had not noticed my posting of this open letter, or the many responses on the Internet, which I commented on today in this blog post for Econsultancy. Thanks to HCHP and Eric Schultz for making good on this coverage.
This is the original blog post: On October 9, 2013, I hand-delivered the following letter to the office of Harvard Pilgrim Health Care CEO Eric Schultz. Since then I have not even received acknowledgement of the letter, nor have I received an appeal form promised me by HPHC patient “support”. Both the denial of the original claim and the HPHC response to my phone and letter communications are utter failures of reasonable customer experience.
Mr. Eric H Schultz
President and CEO
Harvard Pilgrim Health Care
93 Worcester St.
Wellesley, MA, 02481
Mr. Schultz,
I have been a member of HPHC for over 35 years, and in general I have been very happy with the coverage and service. However, I recently have had an experience which has really bothered me.
On Friday, August 9, and Saturday, August 10, I had a sudden increase in floaters in one eye. When they didn’t go away I called the emergency number at Harvard Vanguard and within about 20 minutes an optometrist called me back to tell me that, with my symptoms, I needed to be seen immediately. I was instructed to go to the emergency room at Mass Eye and Ear.
Although I was in northern New Hampshire, my wife drove me down and we arrived at Mass Eye and Ear around 11:30 PM on Saturday. By 2AM Sunday I had been diagnosed with a horseshoe retina tear. I was told that it they could treat it with a laser procedure at 10AM that morning (Sunday), and that it should be done immediately because there was the danger that the retina could detach at any time. So, as the doctor suggested, I went home to sleep and came back at 10AM and had the procedure done and was released at noon. A follow-up visit a week later confirmed that the procedure was effective and that the tear had been sealed, making a detached retina very unlikely.
Subsequently I was informed by Harvard Pilgrim that you would only pay half of the emergency room diagnosis session and none of the laser procedure on Sunday morning because it was not considered an “emergency” procedure, and Mass Eye and Ear is not covered for routine care. I have also been told that Harvard Pilgrim will not cover another short return appointment that the optometrist wants me to have now to be sure that the tear has remained sealed. The unpaid bill to date is over $4,500.
My feeling is that I am being penalized for acting promptly and preventing what could have turned into a far more serious situation, and one that would have been far more expensive for Harvard Pilgrim to cover if the retina had detached.
Apparently, although I was told specifically to go to Mass Eye and Ear’s emergency room by Harvard Vanguard, I was expected to check with Harvard Pilgrim at 2AM on a Sunday morning to see what was and was not covered there. Even if I had tried check with Harvard Pilgrim at 2AM on a Sunday, your website does not list a weekend or emergency number. How could I have gotten an approval?
Recently when I wanted to find out if my follow up visit would be covered I left a voice mail (no one answered the “customer support” line) and filled out a web form. It took HPHC personnel 24 hours to respond to the web inquiry; no one ever returned the phone message. Obviously there was no way for me to get prior approval for this emergency procedure on Sunday.
I think that Harvard Pilgrim’s unwillingness to pay this bill is both unreasonable in my particular case and also calls into question the whole idea of containing healthcare costs through the patient. I’m a well-educated, pro-active individual. But in 35 years of prior experience with HPHC, this had never come up before. And there was no apparent way to go about getting prior approval in a timely manner in the middle of the night.
I hope that Harvard Pilgrim will be paying Mass Eye and Ear in full for the emergency room visit and their successful treatment, and for my follow up visits (hopefully just one more).
Thank you for your attention to this matter.
Sincerely,
Louis Gudema
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