If you've ever had trouble getting your health insurer to reimburse you, Forrest Barker has a few words of advice: Don't give up, and please don't raise your voice with that poor insurance clerk on the other end of the telephone line.
Barker, 70, speaks from experience. Since 1990, he has worked as a volunteer counselor with the Health Insurance Counseling and Advocacy Program, a free service from the California Department of Aging to help Medicare beneficiaries navigate the system.
And, a few months ago, Barker obtained one of the largest and most fiercely fought reimbursements in HICAP's history: $14,137 for a Los Angeles retiree whose husband required several months of costly skilled nursing-home care before his death.
Resolving the case took Barker 2 1/2 years and plenty of patience.
"He's a hero," says Annabel Townsend, the 80-something widow who had all but given up before seeking help from Barker.
Barker is an "aw, shucks" type of guy who refuses to take much credit for the deed. But volunteers like Barker provide an extraordinary service, says Sandra Risdon, who directs HICAP volunteers at the Center for Health Care Rights in Los Angeles.
"It's a tribute to Forrest that he was able to persist. He was able to see a light at the end of the bureaucratic tunnel," she says.
While health insurance reform may be succeeding in lowering costs, it has created massive confusion for many consumers who have witnessed almost yearly changes to their policies. For Medicare recipients, who may also have other retirement benefit insurance policies, the process of filing a claim and fighting the almost-inevitable snafus can be overwhelming, says Risdon.
"Medicare beneficiaries sometimes don't understand their benefits. Our goal is to provide information so that people can make good decisions."
In Los Angeles County, 50 HICAP volunteers serve about 200 clients a month. But with more than 1 million Medicare beneficiaries in the county, Risdon is convinced that many more people could use the program's services.
According to the state Department of Aging, 3,181 Medicare beneficiaries statewide were reimbursed $4.1 million during the past fiscal year through the program's volunteer advocacy efforts.
Townsend, a former first-grade teacher for Los Angeles Unified, was entangled in insurance red tape for two years before seeking Barker's help. Her husband, Bob, fell ill in March, 1990, with Alzheimer's disease and a host of other physical problems. After a 12-day hospitalization in which his health declined dramatically, he was transferred to a nursing home for skilled care. He died in November, 1990.
Townsend paid for the nursing-home care with the couple's small nest egg, which was nearly exhausted when Bob died. Then, she filed an insurance claim to recoup her Medicare co-payments and additional money owed from a secondary policy.
During the next four years, Townsend endured a frustrating battle with her insurer, which, Risdon says, is all too common for elderly Medicare beneficiaries who may not understand their policies or have the energy or ability to fight a large bureaucracy. Two years after Bob's death, Townsend still had not received a dime of the $15,099 owed to her.
"I was worried all the time," says Townsend. "We had a little savings. But the (reimbursement) money was very important to me. It was so frustrating."
According to the insurance company, Blue Shield, the case involved some unusual circumstances and a rare degree of complexity. Mike Odom, a Blue Shield spokesman, says there was never any conscious attempt to withhold money rightfully due Townsend.
But the ensuing snags, says Odom, "were really unfortunate. Sometimes these things happen. You run into a few problems and it becomes a complicated case."
Townsend heard about the HICAP program through a friend, and went to see Barker at the Glendale Adult Recreation Center.
Barker, a former computer and electronics instructor at L.A. City College, is "the right guy in the right job," according to Risdon. He quickly deduced the facts of the case: By June, 1990, the skilled nursing-care benefit in Bob Townsend's Medicare plan had expired, and his retirement health benefit did not cover skilled nursing care.
The Townsends would have been out of luck if not for one thing: Under Annabel Townsend's retirement health package with Blue Shield, one year of skilled nursing-home care was covered in full.
Obtaining the first part of the claim, for $962, would have been simple enough except that Blue Shield sent the check to the nursing home twice instead of to Townsend. Then Barker turned to resolving the remainder of the claim--$14,137 owed by Blue Shield. The insurance company assured Barker it was processing the claim.
That's when things got muddy.
"I called a few weeks later and asked, 'When will you pay the rest of it?' " Barker recalled.
Barker was told the case had been closed and the file sent to Blue Shield's long-term archive warehouse in San Francisco. He was told he had to request that the file be "traced" and reopened.
"I would have given up at that point," says Townsend. "I thought, 'They are just waiting for me to die.' "
But Barker succeeded in getting the file back to Blue Shield's review committee.
"I was just going to do whatever they wanted and needed," he says.
What they wanted was a lot. From the fall of 1993 to early 1994, Barker provided Blue Shield with several forms of documentation. Then, in March 1994, Townsend received a letter from Blue Shield.
Claim denied because she hadn't filed a claim first with Medicare. But she had.
After resolving that snag, which involved Blue Shield overlooking the Medicare paperwork, the claim was once again sent back for processing.
"Long delays were typical of the whole process," says Barker. "Every time I sent them something new they said it had been given to the review committee and it would be six to eight weeks before we got an answer."
In June, 1994, Townsend was informed that Blue Shield needed more information on what kind of medical care her husband had received.
After a letter, many phone calls and two trips to the nursing home to beseech them in person, Barker obtained that documentation and was convinced the saga was coming to a lucrative end. But Townsend was not convinced. She told Barker: "I'll believe it when I see the check."
Her skepticism was warranted. On Oct. 5, Barker was informed that Blue Shield was about to authorize the check but Townsend had to produce proof that she had paid the nursing home.
She came up with two of the four checks she had written, and those were faxed to Blue Shield.
Thirty days later: still no check. Barker called Blue Shield again.
"The agent said, 'Yes, the check is in the mail . . . to the nursing home, ' " Barker says, shaking his head at the unpleasant memory. He then violated one of his own rules. "Well, I raised my voice, which I don't do very often."
The check was stopped and a new one issued. Finally, Townsend received $14,137. The check is safely in the bank and will help her with living expenses and substantial repairs needed to her home stemming from the Northridge earthquake.
"She called me that evening and said 'I have the check!' " Barker recalls. "I told her not to spend it all in one place."
In hindsight, it would have been easier on everyone if, early on, Blue Shield agents had listed all the requirements and documentation Townsend needed to provide for reimbursement, instead of stringing the process along over four years, Barker says.
According to Odom, the Blue Shield spokesman, reimbursement problems like these are rare.
"It was a very complicated case," says Odom. "And the claim was almost a year old by the time she ran it through her coverage. So when she submitted the information, it was as if it was a new claim. We had to go back and substantiate that the benefit was available."
Barker says he never became discouraged.
"I wasn't trying to get something undeserved. It was a straight-forward matter of satisfying all of their requirements."
According to Townsend, everyone but Barker encouraged her to give up her pursuit of the money because of the stress it was creating for her.
"I don't know how to repay him or thank him," she says. "He spent money out of his pocket. He bought envelopes and he drove over here so many times. I sent him a check to cover his expenses but he wouldn't take it."
Barker is typical of HICAP volunteers, who are usually senior citizens, says HICAP's Risdon.
"This was set up as a peer counseling program. Most of the counselors are themselves retired and on Medicare. They have a keen interest in the program," she says.
Counselors spend most of their time educating clients on the system. Advocacy efforts involving a large sum of money, such as the Townsend case, are uncommon.
"This was a magnificent return," says Risdon. "Forrest has a special knack for persisting in difficult and complex cases."
For Barker, the case has reaffirmed his decision to spend his retirement years doing volunteer work instead of "just doing nothing."
"People ask me why I don't go into business professionally and do this," he says. "But it's more satisfying to do it this way."