The Incompetence of Regence Blue Shield

Guest opinion blog post by Jordan.

This post is a recounting of my experience with Regence Blue Shield of Washington ( A horribly unpleasant experience. At the moment we’re still working through this experience. But it contains some information worth sharing, some cautionary tales, and some personal opinions on healthcare in the US today.
To be fair, the insurance industry has a reputation as being uncaring, incompetent, and semi-corrupt. I think most Americans can acknowledge that the insurance status quo is maintained because they are extremely wealthy and able to contribute to the best government money can buy. Because I thought that before this started, I should’ve assumed that everyone at Regence I talked too was incompetent at best, and dishonest at worst. But I didn’t, blindly believing in their training processes, state regulation, and their own oversight and auditing. Too late we realized that Regence and other insurance companies have a lot of ability to do what they want, and the idea of TRUE regulation outside of egregious violations is a farce. They’ve bought and paid for their own regulators and government oversight from the national level all the way down to the state level. Regence Blue Shield
A few statistics to support that line of thinking:
1. According to a report by Health Care for America Now, America’s five biggest for-profit health insurance companies ended 2009 with a combined profit of $12.2 billion. (Note, this is just 5 of the top health insurance companies, not even close to all of the for profit companies and is also 3 years old). 

2. Experts on the Obamacare legislation say the biggest winner was private health insurance companies. Key elements of the legislation that would have proven detrimental to their profitability were cut. American Health Insurance Plans, a super lobby, was estimated to have spent nearly $130 million dollars influencing our government on the final bill. (That’s right, $130 million for one bill).
3. AETNA was estimated to have spent $43 million in California alone on state lobbying efforts in 2009. (One state, one year).
Now you get a sense for how influential the insurance companies are. And how insignificant the individual policy holder really is. With that frame of reference, my story begins.
My wife and I decided to try for our first child in the fall of 2011. In early November, we found out that our first little one (Clara) would be a reality. Immediately, my thoughts went to healthcare coverage. I knew pregnancy can be an extremely expensive healthcare cost. After shopping around, we found a Regence plan called ‘Evolve Plus’ that offered maternity coverage. I knew there was a concern as to whether or not pregnancy was treated as a pre-existing condition in Washington state and called the Regence customer service line to confirm that the Evolve Plus plan would in fact cover my wife’s pregnancy. The customer service representative assured me that pregnancy was covered under the plan.
In December, our coverage was activated. For the next 8 months, we blissfully paid the nearly $300 private premium, paid towards the deductible, and generally didn’t blink an eye towards our insurance coverage. On June 30th, 2012, Clara Loux was born at Good Samaritan hospital in Washington. It was a really amazing experience, and one that is certainly worth any financial cost. I don’t regret having her, and wouldn’t change a thing about having her when we did.
Shortly after her birth, I called Regence to get her added to my wife’s coverage (something we were told we would need to do). Almost immediately after opening this line of inquiry, a helpful CSR who we’ll call M, informed me that my plan covered pregnancy, but not delivery. While the original CSR was correct in that all the prenatal costs for my wife were covered, the actual delivery itself was not covered as it was a pre-existing condition.
Yep. You read that right.
Insurance companies make a distinction between pregnancy and delivery. In the manual its prenatal and postnatal. To me, that seems like a very fine line to draw. Very few pregnancies in the United States that are carried to term end in an outcome other than delivery (whether by vaginal delivery or C-Section). To me, that also seems like a very important line to draw. Up until delivery day, my wife and I had spent nearly $3,000 out of pocket between our deductible and insurance premiums. Regence had covered around $1,700 in costs (that’s right, I could’ve just paid out of pocket and saved $1300). Paying for a low deductible health insurance plan is NOT worth it if they’re only going to cover the prenatal bills (this of course could be different in more problematic pregnancies). Whomever that first CSR was, should have been trained to make that distinction (as M did too late).
Immediately, I started to have alarm bells go off. I knew delivery was expensive. And I knew that Regence was not likely to err in my favor due to a customer service reps incorrect use of terms and lack of clarity. Needless to say, we have an appeal open with Regence now over the $14,000+ in medical bills that should’ve been covered in large part by our insurance plan (one of their premium private plans, mind you). We spent numerous hours on the phone with M and with her direct supervisor trying to get it resolved. We still haven’t heard back on the final appeal status, but we are getting plenty of bills from primary care physicians, pediatricians, the hospitals, anesthesiologists, etc.
Now a few key facts that are worth establishing and are the basis of our appeals:
1. Insurance company CSRs are NOT insurance agents. They’re not supposed to make any recommendations on any plans or coverage. 
They are allowed to offer clarification and definition on plan coverage and features. Insurance agents are more regulated then CSRs because they sell / promote specific products. CSRs do NOT have the same training or expertise or oversight that agents do. Fundamentally, an insurance company should have an obligation to ensure that anyone speaking to the public is trained properly. To that end, Regence CSRs should never be speaking to anyone outside of Regence customers. Frankly, I’m not sure that Regence CSRs should be allowed to answer any questions on the phone, ever (our fiasco with Regence extends beyond the delivery room).
2. Regence Blue Shields CSRs do speak to the public (policy holders or not). 

The Regence website is pretty to look at, but has the fatal flaw of allowing non-policyholders of speaking to their CSR teams (the same teams that aren’t regulated, aren’t trained, and aren’t supposed to be offering anything more then linear information). Their help section / contact us section on the website allows this to happen. Regence also allows people to create accounts after they’ve applied for a policy but before that policy has been accepted. This put my wife and I in the incidental situation of asking questions to this uninformed customer service team.
3. Regence Blue Shield CSRs do make recommendations, just not explicitly.

Legally, they can’t tell you that one plan is better then another. But they can say that this plan covers X and this plan doesn’t. They can say that this plan costs X but this plan costs Y. In everything but the explicit word alone, CSRs seem to have the ability to act as sales people / insurance agents. If they say, “Plan Y is better for you”, that’s a violation of rules. But saying “Plan Y covers A, B, C, and D, which you’re asking for,” is not an issue.
4. Regence Blue Shield CSRs are not trained to make specific clarifications (pregnancy vs. delivery, prenatal vs. postnatal).

From the two CSRs and one supervisor, I spoke to during the wind up for our appeals, this type of information is regularly passed onto the unsuspecting public. They don’t receive training to make the necessary distinctions that will help consumers make the right decision but still do anyways.
While I don’t have much faith that Regence will do the right thing here, I do feel that they should be held accountable for these flaws. Coalition, the small business that I work for, has well documented processes and training manuals that are constantly being improved upon. At 3 years old, we have not had a single instance in over twelve months where a customer felt they were told one thing and then contracted for something different. Regence makes a lot of money, has been around far longer, and serves a much larger audience. I have a hard time believing their process oversight shouldn’t be something they can be liable for. In matters of finance and matters of health, a company should never be allowed to slide with broken training and broken systems and inaccuracies in terminology.
As I’ve hinted at, our saga didn’t end there-
In late July, when it became apparent that Regence was at best suspect, we decided to change our healthcare coverage with them (we didn’t want to cancel fully since I’m not convinced that it could bias our appeals process). We called in and spoke to another CSR (this time we noted date / time / name). We gave her the specifics of the plan that we wanted to move to, and stayed with her on the line till it was done. A week and a half into August, we got a bill for missed payment. We knew we hadn’t missed any payments since they auto deduct from our bank. After calling and talking to another CSR (see a common flaw in Regence yet?), we found out that they had never switched us to the right plan. Once again, we stayed on the line until it was resolved. In late August, we got a bill from Clara’s pediatrician, noting that Regence said she wasn’t covered by any plan. You guessed it, the last 2 CSRs had not only managed to not switch Clara to the new plan, they had managed to lose her from coverage altogether. After another hour on the phone this morning, I’ve been told that ‘Membership’ (a new department) was moving the case to ‘escalation’ and we’ll get the back coverage sorted out and future coverage issues resolved. Needless to say, I’m not all that confident.
Anyways, all of that to sum up a few key learning opportunities for anyone looking at Regence or another insurance provider:
1. Assume that you’re not getting the full story. Do your own research. Talk to more than one person. Talk to friends and family. NEVER trust the insurance company at face value. The internet is only marginally helpful and contains lots of inaccuracies. Talk to an insurance agent. Talk to another insurance agent. Talk to the CSRs. Talk to your mom and dad. Talk to more people.
2. Document everything. Insurance companies won’t do much for you unless you have proof. Note who you talked to, what # you reached them at, what date, what time, what you talked about, and be as specific as possible in note taking on what they say. If possible, record the insurance company representatives (seriously). Of course you have to tell them, but hey, they ‘record your call for quality assurance’- why can’t you keep your own recording?
3. Don’t trust them to do what they say. As we’ve experienced with Regence, most of the people on their ‘teams’ just don’t seem to be able to do the job right the first time. Yes, its an inconvenience, but call back later and talk to someone different to verify the results / outcomes.
4. Remember, in the end, they’re still going to be making a hell of a lot of money. Hopefully by following these guidelines, you are able to be one of the few people who actually cuts into their profit margins. But aside from you, there are millions of others who are blindly being screwed by their insurance company. Try not to be one of those guys.

Nose Bleed

Justin, the third brother in my family, is stricken by the same affliction as I am.  If we reach a certain rage threshold we stop caring about consequences and lash out as hard as we can.  I have had the misfortune of being on the receiving end of his fighting spirit before and it is unpleasant.

When I was about 13 and he was 9ish, we were horsing around around after dinner by our big wooden dining table and I was teasing him and pushing him around.  My dad and other brothers were still sitting down eating and laughing at us.  Justin’s temper kept getting hotter and hotter, but I got him in a bear hug from behind and used my size to keep him from doing anything to me while I harassed him goodnaturedly.  He had had enough though; his face was red and he was steaming mad though there wasn’t much he could do.  Finally his anger thermometer burst.

He bent down at the waist as far as he could, pulling his head and body down into a a standing fetal position.  His head was lowered to down by his knees and with a sudden violent leap used his entire body’s force to slam the back of his head into my nose in a mighty headbutt.

After a stunned second of silence, I flipped him upside down and my dad yelled, “STOP!!!”, just as I started downwards in a piledriver.


I froze and stared at them for a second deciding what to do.  I laughed and flipped Justin right side up and went and got some tissue for my nose.

Dinner with Brother Jordan & Sister-in-Law Meghan

Last night, I had my brother Jordan and his wife Meghan over to my studio apartment in Seattle for dinner.‚  Since it is still rather wintry and cold outside, I made up a pretty hearty meal.‚  Our appetizer was Italian crackers with fresh goat cheese and olive & pepper bruschetta on top.‚  The main course was italian chicken sausage with red peppers, pretty rich mashed potato casserole and sauteed brussell sprouts (a million times better than boiled brussel sprouts).‚  We shared a bottle of merlot with the appetizers and each had a beer with the main meal.‚  Good times.

Jordan and Meghan are doing well.‚  I have three younger brothers, Jordan is the next eldest.‚  Jordan is still working as an upscale furniture salesman, making good money but looking for something new.‚  Meghan is about to start her old job of merchandising various stores again soon.‚  It sounds like they still intend to follow their silly plan of building a house, even though buying a house is much cheaper right now and prices will continue to go down.

We discussed our other two brothers as well.‚  Justin is supposed to be starting up at the UW again, after a layoff he unfortunately forgot to tell me about.‚  Good kids, even if they are a little confused at times.

Heather isn’t at fault

I just read Jordan’s blog entry on Justin staying in school. Jordan’s absolutely correct, Justin must stay in school.

However, I hate how everyone in our family always blames other people when they fail in their responsibilities. If Justin fails in school, it’ll be his own damned fault. He is the idiot who decided he needed to waste his money on a single, he is the one who made a decision to drop a class, he is the one who allows himself to be distracted constantly.

Justin, quit being a coward and stop letting people blame your girlfriend for your own mistakes. Stand up for her or don’t be with her. Don’t let anyone control you either. If I was her, I would leave you if you dropped out. Who wants to date a quitter and a failure? No ones wants to be around someone who has shut their doors and is desperate and sad. You are on that path if you don’t grow some willpower and turn yourself around. Fix it. You have a pretty good example in Jordan; he works full time, has a family and goes to school full time (though his grades could be better).

Jordan, Josh, Mom and everyone else needs to lay off Heather. She is fine, the problem is Justin. Get your shit together, Justin. If you’re too immature to handle a girlfriend at this point in your life along with your other responsibilities, don’t have one.

Jordan: My first friend

Jordan Gross is my second brother; he’s 22, married and lives in Kent. I keep telling him that if he is going to live in the boonies and be married at such a young age, he needs to start his army. Pump out dem babies!!! The world record for most children is 69… I think you can beat it!

Since Jordan and I are only 18 months apart in age, he was my very first friend. In preschool, Jordan and I were best friends and played together constantly. We even took baths together and my mom has a picture of the two of us with a poop floating in the middle.


Like my illustrations? 😉

Jordan and I lived together with my parents until I was 14 and moved in with my grandparents. We regrouped in college, and lived together for a year. I sadly hardly ever saw him though because he worked full-time, went to school full-time and any spare time was spent with his then-fiance Meghan. I think part of the problem may have been that Meghan didn’t like to visit us much because I would occasionally terrify her. Poor Meghan. She grew up in a very strict religious household and is pretty sheltered; this summer her, Jordan and I drove up to my grandparents cabin for the family reunion and she made me tell some of my stories as she listened in fascinated horror. I think her and Jordan have started to view me as some sort of walking freak show.

A couple of weeks ago, I went down to Southcenter mall and visited Jordan at his job selling furniture for Bassett. Bassett Furniture is a strange store; they sell lots of fancy furniture… but seem to have a strange obsession with giant black cocks. Seriously. Walking around their store, they had probably 20 statues of rooster’s scattered around. If they didn’t cost $160, I would’ve purchased one for the infamous Black Rooster, Faryar.


Following in his big brother’s footsteps, Jordan has started a blog. He only has 3 posts so far and speaks in very vague terms, but it’s a start.

All in all, Jordan is a hard worker and will be very successful in his life if he keeps putting in the effort I’ve seen him put forth so far. Jordan is by far the brother with the most social skills and can get along with most people. I proudly take credit for helping him develop these skills… Can you imagine having an ass like me for a big brother? I was stubborn and selfish and would pound on him if I got mad about something, so he had to develop diplomatic talents to better work with me and keep me at bay. A lot of those lessons he had to learn the hard way though… I can still remember sitting in the car with him, while he sang songs to bug me and making faces when our parents weren’t looking and becoming so enraged that I would start hitting him lol.

Jordan is a real sharp guy too. He has a good understanding of the world around him and generally is pretty smart about getting what he wants. If I owned a business, I would hire Jordan to work for me. As a personal assistant.. j/k 😉

My brothers and my grandma are the most important people in my life and I would do anything for them. Great people.

Message from Josh… Never been as proud of one of my bros

Just wanted to thank you for some things,

Lately I have seen the many contradictions the Christian religion has, and it’s many contradictions it makes with itself. I think somewhere inside I’m still trying to cling onto the faith, but every day I begin to see the truth more and more. The only reason I ever really was a Christian was because it made myself feel good to think that there was something out there that could perform a miracle to make my life better, but now I realize all I needed to do was do it myself. Also, we were drilled with religion since we we’re young, and told we would go to hell if we didn’t agree with what God/Bible said. I feel free now, like I took off a heavy weight on my shoulders, it feels better than (deleted lol). Even I now realize how dumb it is to say “cuss” words are bad, people that said they’re bad were the ones who made them bad, after all they’re just words. (Personal… deleted.) And I look forward to satisfy my need for woman, just need to stay safe (hahahhahaha… he’s my blood for sure 😉 ). I wanted to thank you for helping me get out of this religious suck.


Seeing this message blew my mind. I was Josh’s age when I really started to question religion and it was one of the toughest, most thought out decisions I’ve ever made when I moved on to better pastures. For me, it was a process of going back and forth inside my head for several years. I didn’t really start to settle the issues to till I was 16 and it took me two more years to muster the courage and strength of purpose to tell everyone I knew. At that time, every person in my life was religious (entire family and I attended a religious school, so all my friends were the same way). Joshua has thought it out and announced to everyone he knows at the very young age that he will not bow to brainwashing and superstition any longer. He still lives with my abusive father, Randall Gross, and probably will have to put up with a lot of harassment from him and all the other religious people in his life. Josh is a stud though and should be alright. He posted this on his myspace:


As of late I have decided not to join the Freemasons. This is because I do not meet one of the requirements: believe in a Supreme Being. I have lately been questioning the Christian faith. And as I begin to question the religion I realize its many flaws ( contact me and I will tell you why). The only reason why I was ever Christian was because it was drilled into my head that if I wasn’t Christian I would go to Hell, I feel the only reason why I stuck with it until now was out of a fear, but now I see how the religion contradicts itself countless times ( again please contact me again and I will tell you why).

Thank you,


Josh is my new hero.