Fighting for corrections in insurance coverage

Aug. 15--When Joel Piesecki was a kid, he broke the tibia in his leg. After of the bone rubbing against his knee for years, he finally had an MRI to address the pain. The test revealed two things; his pain wouldn't go away and more was coming.

Piesecki is the president of Stroudsburg-based Municipal Software, which provides software solutions for local municipalities. He hires former commuter geeks who gave up their daily trip to the city to join his eight-person company. And they all say they are fighting for the correct coverage with their health insurance provider, Highmark, Inc.

Piesecki's test was confirmed to be in-network, going against his $2,000 annual deductible. Instead, he was billed at an out-of-network price with a $6,000 deductible. It has been happening frequently with his other employees. It takes weeks and valuable time to straighten each case out.

The test was billed as an out-of-network procedure, even though he received a letter saying the procedure was approved and was in-network. The problem, Piesecki thinks, happens when a service is billed at an address different from the one where the service is provided.

"They must have a glitch with their software," he said.

The customer service is not any better, Piesecki said. Municipal Software is assigned a new representative constantly, who must be brought up to date on all the issues.

And the representative always promises to fix it, even when they don't, he said.

"At least they can be honest with us," Municipal Software Benefits Administrator Dave Forte said. He is the one who has to straighten out all these issues.

Worse yet, Piesecki claims the Highmark keeps moving its benefits period and resetting the deductibles. Two Explanation of Service Documents Piesecki presented to the Pocono Record clearly show different benefits periods for procedures done in the spring. One shows the year beginning Nov. 1. The other shows the year beginning Jan 1.

"They have to start all of the payments over that they've made against their deductibles since November," Piesecki said.

As if the matter was not complicated enough, Municipal Software has an employer-based health savings account. It works by having the employer, Municipal Software, only require employees to pay the first $500 of their deductible, with the company paying the rest of the deductible. So every time a procedure is billed at the out-of-network deductible, the company has to fight to get the proper amount billed.

The company filed a complaint against Highmark through the Pennsylvania Insurance Department. All it got them was attitude and complaints from the company about filing a dispute, Piesecki said. And the Explanation of Benefits, Forte said, is still wrong.

Ali Fogarty of the Pennsylvania Insurance Department, which regulates these disputes, said if the individual making the complaint is not satisfied with the result stemming from the complaint, they should contact the person on the letter they received regarding the complaint.

Highmark did not provide a reply to Municipal Software's complaints.

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