Possible ADA Violation

[Seamus2014]

What is the name of your state (only U.S. law)? Wisconsin

I’m an abuse/fraud investigator for a small health insurance company. I investigate and end up denying charges on services that aren’t medically necessary, E/I, upcoded, out-of-network, etc. et al. And I save millions a year doing it.

Problem is, we can never stop the providers from then balance billing the patients for whatever we deny. Needless to say, that makes for a lot of unhappy people. To which, unlike the previous company I did this for, this company has made me the de facto person who is then expected to let these people call up and scream at me, or cry at me, or whatever have you. And these are people who may have cancer, or went to the hospital for chest pain, etc.—basically, people who they themselves did nothing wrong, but the doctor ordered a procedure or test that was outside the norm and deemed not medically necessary after review.

Through a set of circumstances too long to go into, I realized I might be experiencing a form of trauma called “vicarious.” Generally affects cops or medical professionals or even lawyers; basically, you see enough people go through bad things, it begins to affect you emotionally. I.E., a cop sees a dead teenager and his daughter is a teenager, he personalizes it more. Not all the symptoms fit and I don’t profess to be on the same level as a cop or that, but you do see/read/hear a lot of bad stories in this industry as well.

And then I’m also being made to talk to these people and personalizing it myself. More so, I started feeling like I was the one responsible for their situations. If I wasn’t doing this job, their service wouldn’t have been denied and they wouldn’t be responsible for $10,000. I began to feel like a horrible person for doing my job, to the point it was affecting my relationships with my wife, my daughter, my other family and even my friends.

I bit the bullet and went to see a psychiatrist to see if this was a real thing, and her professional assessment was yes. Absolutely. She also said she can’t think of any other profession where someone makes adverse determinations like I do that negatively affect people’s lives, and then is also supposed to be the one to listen to those people complain about it afterwards. There should be a buffer zone, in other words. That’s why I was feeling the way I was, I’ve been “personalizing” these files. It’s hard enough to make that kind of decision sometimes when they’re just names on a piece of paper; it exacerbates it when you talk to them and (even if they’re nice, which some of them are and that is almost worse than them screaming sometimes) they become more “real.”

Her professional recommendation was that I explain this to my employer and that I no longer wanted to field calls from patients—which by the way, was never in any formal job description or even review I’ve ever had (i.e., I wouldn’t consider it an “essential” function of the job).

So I did in an e-mail (I’ve made sure to put all this in writing and save it) asking for the reasonable accommodation of me no longer fielding calls from patients. I made it clear that I didn’t mind taking calls from doctors, hospitals, brokers, clients, attorneys. Just not patients any more due to this.

This would not be an undue hardship on them; we have many third party advocacy programs in place (like large case management) and our company doesn’t pay for it, the clients do. The patients do need someone to turn to when something is denied—it just shouldn’t be the same person who actually did the denial because ultimately I’m acting in the best interests of the Plan overall, not them.

The e-mail was, I thought, well received with my manager saying she would “fight for me.” She only answers to the two owners of the company.

It’s now been a month and beyond her pulling me into a room one day to ask if I wanted to apply for another position opening up (which would be a substantial reduction in pay), I haven’t heard one word about it. I told her on the position that I was completely happy doing what I was doing save for that aspect of it.
I’m guessing she went to the owners and they told her to clam up until or unless they talk to their lawyers.

It’s my understanding from my psychiatrist and my own research that this condition (which my psychiatrist also classifies under anxiety/stress) is protected under the ADA and Wisconsin law, and that they are supposed to engage in conversation with me about my reasonable accommodation request and try to meet me halfway, at least. My psychiatrist has also said that she would write a letter or cooperate in any way with any requests my employer might have to address this.
I plan on sending a follow-up e-mail next week, but to be honest knowing how this company works, I don’t expect to get a response then, either.

My question is, how long should I give them to respond before I talk to a lawyer about a potential violation of the ADA or WI law?

Barring that, if they still ignore my request, would I possibly even be able to quit and receive UI benefits?

I’m not looking to file a frivolous lawsuit; I don’t want to go court. I’m not looking for a settlement or anything like that. That’s not what this is about. It’s about my mental health. I have been looking for another job (and did have an interview the other day) but obviously that process can take weeks or months, and all things considered, don’t want to wait that long. If they’re not going to accommodate my request, then I just ultimately want out, but needless to say I can’t just get out without at least UI or another job lined up.

Any thoughts or advice would be greatly appreciated.

 

[ecmst12]

Having a depressing job does not make you disabled. It just means you need to find a new line of work.

 

[Ladyback1]

What is the name of your state (only U.S. law)? Wisconsin

I’m an abuse/fraud investigator for a small health insurance company. I investigate and end up denying charges on services that aren’t medically necessary, E/I, upcoded, out-of-network, etc. et al. And I save millions a year doing it.

Problem is, we can never stop the providers from then balance billing the patients for whatever we deny. Needless to say, that makes for a lot of unhappy people. To which, unlike the previous company I did this for, this company has made me the de facto person who is then expected to let these people call up and scream at me, or cry at me, or whatever have you. And these are people who may have cancer, or went to the hospital for chest pain, etc.—basically, people who they themselves did nothing wrong, but the doctor ordered a procedure or test that was outside the norm and deemed not medically necessary after review.

Through a set of circumstances too long to go into, I realized I might be experiencing a form of trauma called “vicarious.” Generally affects cops or medical professionals or even lawyers; basically, you see enough people go through bad things, it begins to affect you emotionally. I.E., a cop sees a dead teenager and his daughter is a teenager, he personalizes it more. Not all the symptoms fit and I don’t profess to be on the same level as a cop or that, but you do see/read/hear a lot of bad stories in this industry as well.

And then I’m also being made to talk to these people and personalizing it myself. More so, I started feeling like I was the one responsible for their situations. If I wasn’t doing this job, their service wouldn’t have been denied and they wouldn’t be responsible for $10,000. I began to feel like a horrible person for doing my job, to the point it was affecting my relationships with my wife, my daughter, my other family and even my friends.

I bit the bullet and went to see a psychiatrist to see if this was a real thing, and her professional assessment was yes. Absolutely. She also said she can’t think of any other profession where someone makes adverse determinations like I do that negatively affect people’s lives, and then is also supposed to be the one to listen to those people complain about it afterwards. There should be a buffer zone, in other words. That’s why I was feeling the way I was, I’ve been “personalizing” these files. It’s hard enough to make that kind of decision sometimes when they’re just names on a piece of paper; it exacerbates it when you talk to them and (even if they’re nice, which some of them are and that is almost worse than them screaming sometimes) they become more “real.”

Her professional recommendation was that I explain this to my employer and that I no longer wanted to field calls from patients—which by the way, was never in any formal job description or even review I’ve ever had (i.e., I wouldn’t consider it an “essential” function of the job).

So I did in an e-mail (I’ve made sure to put all this in writing and save it) asking for the reasonable accommodation of me no longer fielding calls from patients. I made it clear that I didn’t mind taking calls from doctors, hospitals, brokers, clients, attorneys. Just not patients any more due to this.

This would not be an undue hardship on them; we have many third party advocacy programs in place (like large case management) and our company doesn’t pay for it, the clients do. The patients do need someone to turn to when something is denied—it just shouldn’t be the same person who actually did the denial because ultimately I’m acting in the best interests of the Plan overall, not them.

The e-mail was, I thought, well received with my manager saying she would “fight for me.” She only answers to the two owners of the company.

It’s now been a month and beyond her pulling me into a room one day to ask if I wanted to apply for another position opening up (which would be a substantial reduction in pay), I haven’t heard one word about it. I told her on the position that I was completely happy doing what I was doing save for that aspect of it.
I’m guessing she went to the owners and they told her to clam up until or unless they talk to their lawyers.

It’s my understanding from my psychiatrist and my own research that this condition (which my psychiatrist also classifies under anxiety/stress) is protected under the ADA and Wisconsin law, and that they are supposed to engage in conversation with me about my reasonable accommodation request and try to meet me halfway, at least. My psychiatrist has also said that she would write a letter or cooperate in any way with any requests my employer might have to address this.
I plan on sending a follow-up e-mail next week, but to be honest knowing how this company works, I don’t expect to get a response then, either.

My question is, how long should I give them to respond before I talk to a lawyer about a potential violation of the ADA or WI law?

Barring that, if they still ignore my request, would I possibly even be able to quit and receive UI benefits?

I’m not looking to file a frivolous lawsuit; I don’t want to go court. I’m not looking for a settlement or anything like that. That’s not what this is about. It’s about my mental health. I have been looking for another job (and did have an interview the other day) but obviously that process can take weeks or months, and all things considered, don’t want to wait that long. If they’re not going to accommodate my request, then I just ultimately want out, but needless to say I can’t just get out without at least UI or another job lined up.

Any thoughts or advice would be greatly appreciated.

I'm sorry but "listening" to the "horror stories" in no way is comparable to a police officer witnessing a "horror story".....
(and telling me I "just don't understand" is not going to work---former claims examiner and 911 Dispatcher, I was subjected to some pretty ugly phone calls! I understand far more than you can believe...)

Not fielding calls may NOT be a reasonable accommodation for your employer. Furthermore, have you followed proper procedure for requesting ADA status and requesting reasonable accommodations? I'm thinking not, because there was no mention of your employer asking for a statement from your medical provider about why the accommodation is necessary. All you've done is send an email. There are actual forms that need to be completed!

 

[cbg]

If I wasn’t doing this job, their service wouldn’t have been denied and they wouldn’t be responsible for $10,000.

Bullcookies. If you weren't doing this job, someone else would; it would still be denied and they'd still be responsible for $10,000.

I understand far better than you may think also. I've had to do exactly what you're complaining about; I've also had to tell new parents that they can't add their newborn child to their health insurance or that just because their supervisor said they'd be eligible for dental insurance didn't mean they were eligible and yes, you can pay your $30,000 dental bill all by yourself. So don't tell me I can't understand.

That said, no, I do not think you've got any kind of recourse under the ADA.

 

[Proserpina]

What is the name of your state (only U.S. law)? Wisconsin

I’m an abuse/fraud investigator for a small health insurance company. I investigate and end up denying charges on services that aren’t medically necessary, E/I, upcoded, out-of-network, etc. et al. And I save millions a year doing it.

Problem is, we can never stop the providers from then balance billing the patients for whatever we deny. Needless to say, that makes for a lot of unhappy people. To which, unlike the previous company I did this for, this company has made me the de facto person who is then expected to let these people call up and scream at me, or cry at me, or whatever have you. And these are people who may have cancer, or went to the hospital for chest pain, etc.—basically, people who they themselves did nothing wrong, but the doctor ordered a procedure or test that was outside the norm and deemed not medically necessary after review.

Through a set of circumstances too long to go into, I realized I might be experiencing a form of trauma called “vicarious.” Generally affects cops or medical professionals or even lawyers; basically, you see enough people go through bad things, it begins to affect you emotionally. I.E., a cop sees a dead teenager and his daughter is a teenager, he personalizes it more. Not all the symptoms fit and I don’t profess to be on the same level as a cop or that, but you do see/read/hear a lot of bad stories in this industry as well.

And then I’m also being made to talk to these people and personalizing it myself. More so, I started feeling like I was the one responsible for their situations. If I wasn’t doing this job, their service wouldn’t have been denied and they wouldn’t be responsible for $10,000. I began to feel like a horrible person for doing my job, to the point it was affecting my relationships with my wife, my daughter, my other family and even my friends.

I bit the bullet and went to see a psychiatrist to see if this was a real thing, and her professional assessment was yes. Absolutely. She also said she can’t think of any other profession where someone makes adverse determinations like I do that negatively affect people’s lives, and then is also supposed to be the one to listen to those people complain about it afterwards. There should be a buffer zone, in other words. That’s why I was feeling the way I was, I’ve been “personalizing” these files. It’s hard enough to make that kind of decision sometimes when they’re just names on a piece of paper; it exacerbates it when you talk to them and (even if they’re nice, which some of them are and that is almost worse than them screaming sometimes) they become more “real.”

Her professional recommendation was that I explain this to my employer and that I no longer wanted to field calls from patients—which by the way, was never in any formal job description or even review I’ve ever had (i.e., I wouldn’t consider it an “essential” function of the job).

So I did in an e-mail (I’ve made sure to put all this in writing and save it) asking for the reasonable accommodation of me no longer fielding calls from patients. I made it clear that I didn’t mind taking calls from doctors, hospitals, brokers, clients, attorneys. Just not patients any more due to this.

This would not be an undue hardship on them; we have many third party advocacy programs in place (like large case management) and our company doesn’t pay for it, the clients do. The patients do need someone to turn to when something is denied—it just shouldn’t be the same person who actually did the denial because ultimately I’m acting in the best interests of the Plan overall, not them.

The e-mail was, I thought, well received with my manager saying she would “fight for me.” She only answers to the two owners of the company.

It’s now been a month and beyond her pulling me into a room one day to ask if I wanted to apply for another position opening up (which would be a substantial reduction in pay), I haven’t heard one word about it. I told her on the position that I was completely happy doing what I was doing save for that aspect of it.
I’m guessing she went to the owners and they told her to clam up until or unless they talk to their lawyers.

It’s my understanding from my psychiatrist and my own research that this condition (which my psychiatrist also classifies under anxiety/stress) is protected under the ADA and Wisconsin law, and that they are supposed to engage in conversation with me about my reasonable accommodation request and try to meet me halfway, at least. My psychiatrist has also said that she would write a letter or cooperate in any way with any requests my employer might have to address this.
I plan on sending a follow-up e-mail next week, but to be honest knowing how this company works, I don’t expect to get a response then, either.

My question is, how long should I give them to respond before I talk to a lawyer about a potential violation of the ADA or WI law?

Barring that, if they still ignore my request, would I possibly even be able to quit and receive UI benefits?

I’m not looking to file a frivolous lawsuit; I don’t want to go court. I’m not looking for a settlement or anything like that. That’s not what this is about. It’s about my mental health. I have been looking for another job (and did have an interview the other day) but obviously that process can take weeks or months, and all things considered, don’t want to wait that long. If they’re not going to accommodate my request, then I just ultimately want out, but needless to say I can’t just get out without at least UI or another job lined up.

Any thoughts or advice would be greatly appreciated.

There is only one condition which automatically qualifies for ADA protection.

And yours ain't it.

 

[justalayman]

If I wasn’t doing this job, their service wouldn’t have been denied and they wouldn’t be responsible for $10,000.

Bullcookies. If you weren't doing this job, someone else would; it would still be denied and they'd still be responsible for $10,000.

I understand far better than you may think also. I've had to do exactly what you're complaining about; I've also had to tell new parents that they can't add their newborn child to their health insurance or that just because their supervisor said they'd be eligible for dental insurance didn't mean they were eligible and yes, you can pay your $30,000 dental bill all by yourself. So don't tell me I can't understand.

That said, no, I do not think you've got any kind of recourse under the ADA.

Seamus, please realize cbg is the nice one around here. Given she sounds a bit put off I would take that your argument sounds kind of over reaching.


I'm curious though whether Ada is even in play here. Given your boss answers directly to the owners suggests the company is quite small. How many employees are there in the company?


And asking the company to change their business model ( your argument that they could eliminate the job duties in house) is not an available accommodation. They still get to operate their business as they choose. All the Ada requires is they make an accommodation, if possible and reasonable, to allow you to perform your job duties. While sometimes that can include you transferring to a different position, it does not mean they would have to create a position for you and that is essentially what you are asking them to do.

 

[commentator]

"Barring that, if they still ignore my request, would I possibly even be able to quit and receive UI benefits?

Not a chance. I'm going out on a limb here, because as most will know, I rarely ever say "NO!" I usually qualify my predictions regarding unemployment eligibility. But really, you must show that you have a valid, work related reason to quit the job, that you have left after exhausting every reasonable alternative, and that you are able and available for equivalent work. If you try to claim a legitimate disability, then you are restricting the type of work you can do in the future, and that won't fly. Your psychiatrist is right, your job is miserable and its driving you crazy, but it's the work you signed up to do, and you've been doing it for several years, from the sound of things, and that it's now upsetting to you is very likely not going to be considered a legitimate reason to quit the job for unemployment purposes.

You are claiming that you have some sort of anxiety related condition that is caused by the nature of your work. You have asked for accommodation, and it has been denied to you, majorly because, duh, the job you are doing is exactly what you are doing. You want to cut people off, deny their claims, refuse the tests that their doctor may have told them are life sustaining and necessary for their treatment, and then you don't want to have to field the repercussions of this work, which is that you have to deal with people who are upset with you because you have denied them the treatment, test, procedure, etc., that they have been recommended by their physician.

You work for a health care company. Those folks are ALL about the profits, let me tell you. Do you honestly think that they would give half a hoot about your mental stability or your stress level while you are busily engaged in making money for them? If you can no longer do the job, or no longer want to do the job that you signed up to do, do you really believe they're going to give you another job that pays equivalent? No, they're not required to do it legally, so they'll boot you and find another warm body that they can hand the manuals to and have them fill your spot.

And in today's employment climate, do you think that in Wisconsin, the great state where your gov has recently broken unions and bragged about it, that they are going to give you one minute of consideration when it's between you and the employer and there's no law that has been broken here?

My health issues have caused me to have many experiences with people who have the job you have. In fact, just as I was dealing with them hot and heavy, was one of those callers who was causing some guy like you a little stress, my son was graduating from college. Our state being a big health care company center, those health care distribution companies such as the one you work for were recruiting actively on his campus. All that was required was a degree in something. I told him that I would prefer he worked at Burger King or construction work than that he ever took a job of this sort where he, with no medical expertise, nothing but a rule book in front of him, would be making life and death decisions about people's health care. I would disown him. I'd rather he worked in just about any honest work than in a job like this, which I consider actually immoral.

You've had your run with this company, you seriously need to find something else to do.

 

[CSO286]

What is the name of your state (only U.S. law)? Wisconsin

I’m an abuse/fraud investigator for a small health insurance company. I investigate and end up denying charges on services that aren’t medically necessary, E/I, upcoded, out-of-network, etc. et al. And I save millions a year doing it.

Problem is, we can never stop the providers from then balance billing the patients for whatever we deny. Needless to say, that makes for a lot of unhappy people. To which, unlike the previous company I did this for, this company has made me the de facto person who is then expected to let these people call up and scream at me, or cry at me, or whatever have you. And these are people who may have cancer, or went to the hospital for chest pain, etc.—basically, people who they themselves did nothing wrong, but the doctor ordered a procedure or test that was outside the norm and deemed not medically necessary after review.

Through a set of circumstances too long to go into, I realized I might be experiencing a form of trauma called “vicarious.” Generally affects cops or medical professionals or even lawyers; basically, you see enough people go through bad things, it begins to affect you emotionally. I.E., a cop sees a dead teenager and his daughter is a teenager, he personalizes it more. Not all the symptoms fit and I don’t profess to be on the same level as a cop or that, but you do see/read/hear a lot of bad stories in this industry as well.

And then I’m also being made to talk to these people and personalizing it myself. More so, I started feeling like I was the one responsible for their situations. If I wasn’t doing this job, their service wouldn’t have been denied and they wouldn’t be responsible for $10,000. I began to feel like a horrible person for doing my job, to the point it was affecting my relationships with my wife, my daughter, my other family and even my friends.

I bit the bullet and went to see a psychiatrist to see if this was a real thing, and her professional assessment was yes. Absolutely. She also said she can’t think of any other profession where someone makes adverse determinations like I do that negatively affect people’s lives, and then is also supposed to be the one to listen to those people complain about it afterwards. There should be a buffer zone, in other words. That’s why I was feeling the way I was, I’ve been “personalizing” these files. It’s hard enough to make that kind of decision sometimes when they’re just names on a piece of paper; it exacerbates it when you talk to them and (even if they’re nice, which some of them are and that is almost worse than them screaming sometimes) they become more “real.”

Her professional recommendation was that I explain this to my employer and that I no longer wanted to field calls from patients—which by the way, was never in any formal job description or even review I’ve ever had (i.e., I wouldn’t consider it an “essential” function of the job).

So I did in an e-mail (I’ve made sure to put all this in writing and save it) asking for the reasonable accommodation of me no longer fielding calls from patients. I made it clear that I didn’t mind taking calls from doctors, hospitals, brokers, clients, attorneys. Just not patients any more due to this.

This would not be an undue hardship on them; we have many third party advocacy programs in place (like large case management) and our company doesn’t pay for it, the clients do. The patients do need someone to turn to when something is denied—it just shouldn’t be the same person who actually did the denial because ultimately I’m acting in the best interests of the Plan overall, not them.

The e-mail was, I thought, well received with my manager saying she would “fight for me.” She only answers to the two owners of the company.

It’s now been a month and beyond her pulling me into a room one day to ask if I wanted to apply for another position opening up (which would be a substantial reduction in pay), I haven’t heard one word about it. I told her on the position that I was completely happy doing what I was doing save for that aspect of it.
I’m guessing she went to the owners and they told her to clam up until or unless they talk to their lawyers.

It’s my understanding from my psychiatrist and my own research that this condition (which my psychiatrist also classifies under anxiety/stress) is protected under the ADA and Wisconsin law, and that they are supposed to engage in conversation with me about my reasonable accommodation request and try to meet me halfway, at least. My psychiatrist has also said that she would write a letter or cooperate in any way with any requests my employer might have to address this.
I plan on sending a follow-up e-mail next week, but to be honest knowing how this company works, I don’t expect to get a response then, either.

My question is, how long should I give them to respond before I talk to a lawyer about a potential violation of the ADA or WI law?

Barring that, if they still ignore my request, would I possibly even be able to quit and receive UI benefits?

I’m not looking to file a frivolous lawsuit; I don’t want to go court. I’m not looking for a settlement or anything like that. That’s not what this is about. It’s about my mental health. I have been looking for another job (and did have an interview the other day) but obviously that process can take weeks or months, and all things considered, don’t want to wait that long. If they’re not going to accommodate my request, then I just ultimately want out, but needless to say I can’t just get out without at least UI or another job lined up.

Any thoughts or advice would be greatly appreciated.

Ever work in child support?????

 

[CdwJava]

he also said she can’t think of any other profession where someone makes adverse determinations like I do that negatively affect people’s lives, and then is also supposed to be the one to listen to those people complain about it afterwards.

Let's see ... arrests and seizing kids negatively affect people's lives ... listening to complains from people who have lost their jobs as a result of an arrest, or complaints about officers, courts, the law, or a myriad of other things that we don't have control over ... yeah, there are other professions that have to deal with this crud. If we don't like it, or it gets to us, we don't have an ADA claim, we have to get out.