Seamus2014
Junior Member
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 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.