Firstly, I would like to say that this is not e-begging. This is for my friend who is not on reddit for privacy reasons, and I am posting on behalf of her.
My friend has Sjogren syndrome and Rheumatoid arthritis and other autoimmune diseasse. She is only 34 but has had these disease for over a decade, and she requires a combination of medications. She is self-employed (around 50K take home after all taxes and whatnot) in Texas, and Texas does not recognize the Affordable Care Act (ACA) as constitutional, and so people like my friend ("Amanda") who do not have other options for insurance are relegated to policies offered on the ACA marketplace. Because she has debilitating healthcare conditions, she has to pay for a very expensive policy that still covers very little. She pays $500 per month for premium to BCBS-texas with deductible of 850 and 8700 out of pocket max. Her deductiblewas met on Jan 7th, and and OOP were met on Jun 1st.
recently, when she tried to go to the pharmacy, she hasn't been pick up her medication without paying exorbitant prescription co-pays, even with manufacturer coupons because BCBS suddenly changed their mind about how much she had paid toward her out of pocket maximum. She has a full list of all the claims from her insurance profile page that shows her contribution, insurance discount and paid amount toward the out of pocket. Here is the history of claims with claim number and personal info removd.
The craziest thing is that her deductible and the out-of-pocket expense kept changing over the week multple times a day, almost like they are trying to fabricate numbers**.** This is how the OOP paid amount changed**:**
Date Out of Pocket Paid (max 8700)
Jun 1 8700
July 24 6216.16
Aug 4 9267.07
Aug 8th 6515.33
Aug 9 9337.07
Aug 10 9504.51
Aug 11 7:34Am 9324.82
Aug 11 1:32PM 9494.51
Aug 12 7:56Am 9504.51
Aug 12 11;27AM 7010.67
Aug 12 2:37APM 7014.08
Aug 15 5:21AM 7014.08
BCBS-TX emailed her on Aug 12 that "there has been a reversal of charges and they are not fully processed in our system making it appear that your OOP maximum had been met." And later that day, they sent her another email that "prescription claim on April 20 for $2493.84 were reversed for a copay assist and $500 was applied to OOP as patient responsibility portion. After the update for 2022 accumulation has been completed, the totals met are now: $850/$850 deductible and $7010.57/8700 out of pocket maximum with remaining $1689.33."
She has filed complaint to Department of Insurance and federal HHS discrimination claim...and I think this is the worst bullshit I have seen because it looks like insurance can just reverse charges at whim and call it "adjustment" when no reasons have been given. When she contested what the grounds of reversal was, they simply told her to look at "Explanation of Benefits," but the problem is that out of 329 claims she has filed, 286 of them don't show up in the system (EOB is not available at this time) but this image. All her pharmacies see this screenshot so no one knows what changed and the details. At this point she doesn't trust BCBS to provider her EOB for those claims. She now owes over $2000 to the pharmacy, too.
Oher than filing complaint with DOi and HHS, what is the best course of actions she can take? What's to stop BCBS from suddenly reversing any charges arbitrarily in the future? I also have BCBS in different state and knew that their customer service is in general abysmal but never thought this kind of circus show will happen to my close friend.