What insurers are doing to fix their rap for awful customer service

Cindi Rountree knew she was fed up with her health insurer after she was told she had to drive 80 miles if she wanted to buy a new breast prosthesis at a lower, in-network rate.

That was not the only challenge Rountree, a breast cancer survivor, had with her insurer, the now-defunct Kentucky Health Cooperative.

She had to fight to have a colonoscopy designated as a screening—a free service under the Affordable Care Act. The test was originally billed as diagnostic, which led to an unexpected charge of $217.20. Her allergist's office also asked her to call the insurer about why the office's claims were not being paid.

Rountree's experience with the co-op's customer service began inauspiciously in 2014, when Kentucky Health Cooperative repeatedly misspelled her name on her insurance card and bills. Over the course of two years, the insurer inundated Rountree with numerous explanations of benefits for diagnostic tests, breast exams and other routine procedures that told her she owed money even though she thought she was in the clear. Rountree provided copies of the paperwork to Modern Healthcare.

“I was livid,” said Rountree, 52, who lives in Louisville with her husband, Doug, and their 12-year-old son, Caleb.

Rountree's experience provides a glimpse into the failures of the ACA's co-ops, which were both underfunded and underpriced. But her frustrations, and those of many other people who have voluntarily reached out to Modern Healthcare, also show that health insurance companies of all sizes still have not mastered the art of customer service. It's somewhat unsurprising that an August 2015 poll from the Kaiser Family Foundation found people ranked health insurance companies almost as unfavorably as pharmaceutical companies and oil conglomerates, due in no small part to insurers' reputation for poor customer service.

The Rountrees were among the thousands of people covered by Kentucky Health Cooperative, one of the not-for-profit co-ops that were funded with taxpayer loans authorized by the ACA. By the time the exchanges were set to go live in late 2013, an insurance broker directed Rountree and her family to Kentucky Health Cooperative.

Initially, the health plan was a no-brainer. The Rountrees paid $795 per month for their co-op plan in 2014 with no premium subsidies (they made too much to qualify for the subsidies that year) and $929 per month for their plan in 2015 after accounting for $136 in premium subsidies. Even though the premium increased sharply, the middle-class family was able to be on the same policy—Cindi used to be on her own plan because of her cancer diagnosis from 2007, while Doug and Caleb were insured separately. It also was cheaper and more comprehensive than what they had before the ACA, she said.

“The insurance companies just see cancer, so my rates skyrocketed,” Rountree said of her pre-ACA options.

She and her family stayed with Kentucky Health Cooperative until it unexpectedly closed last year. Sixteen co-ops have shuttered nationwide. During that two-year span, Rountree said she felt like the main character from Dr. Seuss' book Horton Hears a Who!, praying that someone within the health insurance bureaucracy or state government could help her.

“I'm yelling and yelling, and no one's listening,” Rountree said.

Some reviewers on the Better Business Bureau website called Kentucky Health Cooperative “absolutely worthless” and said it was a “disgrace” run by “criminals.” And while consumers with negative experiences naturally are more motivated to voice their travails, a November 2015 letter from the Kentucky Department of Insurance to Rountree showed the co-op had “more than 4,000 complaints/claims issues to investigate.”

The Kentucky co-op is not an isolated incident of customer service gone awry. A May 2016 report from California's Office of the Patient Advocate found that insurance agencies in the state resolved more than 27,000 health insurance complaints in 2014, ranging from claims denials to questions about copays, coinsurance and deductibles. The CMS' Office of the Medicare Ombudsman (PDF) fielded more than 97,000 online and phone complaints from people enrolled in Medicare Advantage and Part D plans in 2013, according to the office's most recent report to Congress.

“The generalized statement that insurance companies are second in line to used-car salesmen, we're aware of that,” said Ali Skinner, head of public relations at CDPHP, a health plan based in Albany, N.Y. But many companies, like CDPHP, have been working to retool that image by engaging with members, transparently adjusting provider networks and ensuring people understand their benefits and definitions of terms from the outset.

CDPHP's commercial health plans had a rating of 5 last year from the National Committee for Quality Assurance, the highest possible rating on the 1-5 scale. CDPHP also had a 4.5 rating on its Medicaid and Medicare Advantage plans. Skinner said one of the biggest reasons the not-for-profit plan has been able to garner high NCQA scores stems from its enhanced primary-care program.

CDPHP pays doctors more if they expand office hours, conduct longer office visits with patients and communicate via email and phone. The physicians within the network are generally happier to receive the higher payments and spend more time with patients. “That trickles down to the members as well,” Skinner said and results in fewer complaints tied to the plan's provider network.

Insurers and the companies that work directly with them also are becoming more aware that not all members have a proficient understanding of their health benefits, which have become more complicated with tiered and narrow networks and varying levels of cost-sharing.

“We have exceptionally high levels of healthcare illiteracy,” said Dr. Rajaie Batniji, chief health officer of Collective Health, a venture capital-backed technology firm that manages health benefits for self-insured employers. “That's why most people don't even fight that fight. They go bankrupt. They pay bills they probably shouldn't have paid.”

Batniji and CEO Ali Diab co-founded Collective Health a few years ago after Diab battled his insurer over a big bill for an emergency department visit.

They were both fed up with confusing billing statements and the lack of streamlined help. Collective Health takes over the entire back-end insurance process for employers, from managing vendors to claims adjudication, so that workers only have to interact with a single source.

“If you can resolve an issue and a member doesn't have to call 50 times to deal with it, you've actually created efficiency,” Batniji said.

UPMC Health Plan, owned by the Pittsburgh-based UPMC hospital system, similarly tries to obviate the need for members to call. The insurer handled 2.5 million inbound calls last year but also made 800,000 outbound calls. Those outgoing calls are made to people who have upcoming appointments or who will benefit from knowing what their cost-sharing will be when they reach the doctor's office.

“The anger comes when they're surprised,” said Mary Beth Jenkins, chief operating officer of UPMC Health Plan, which has grown its membership by 8% in the past year and has high member satisfaction marks. “We're trying to do it in a setting where a customer isn't calling us frustrated about a bill.”

By responding to consumers' venting posts on Facebook, Instagram and Twitter, insurers can snuff out members' problems before they erupt into something bigger. CDPHP routinely scours social media and responds to about 20 comments per month, Skinner said.

In some ways, the health insurance industry will always have to deal with consumers lodging complaints, similar to how airlines expect some of their customers will be unhappy with their flights no matter what the service is like. That's increasingly true as more insurers and employers push people into high-deductible health plans.

Employers and insurers have changed their policies to shift more of the cost to consumers, said Christine Paige, senior vice president of marketing and digital services at Kaiser Foundation Health Plan. “People are less satisfied, all things being equal, when you have to pay a good deal more for something.”

But Batniji of Collective Health believes insurers have much more control over their communication and processes. “There's nothing inherent in insurance that means customer service has to be difficult or frustrating,” he said. He notes that USAA—a Texas-based company that offers a variety of insurance products, including some types of health insurance—has some of the highest customer service marks of any company in any industry.

In Louisville, Cindi Rountree and her family now pay $400 a month for coverage through Samaritan Ministries, a Christian healthcare sharing ministry. People who get coverage through sharing ministries are exempt from the ACA's individual mandate penalty and avoid the red tape associated with insurers.

The Rountrees have to pay the first $300 in medical expenses out of pocket, but any amount after that can be submitted to the ministry. Rountree has put her experiences with Kentucky Health Cooperative in the past, and she and her family are happy with their new coverage.

“We were just so tired of healthcare insurance and the hassles,” Rountree said. “I'm pretty gun-shy about going back to regular health insurance.”