AccountId: 011433970860
ContactId: 225dc0d9-c3d9-41ea-aea6-4b134ff65ce1
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1196099 ms
Total Talk Time (AGENT): 495470 ms
Total Talk Time (CUSTOMER): 549646 ms
Interruptions: 8
Overall Sentiment: AGENT=0.1, CUSTOMER=-1.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/21/225dc0d9-c3d9-41ea-aea6-4b134ff65ce1_20250221T13:51_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yes, and I was calling.
[CUSTOMER][NEUTRAL] To inquire about a claim that's been processed?
[AGENT][POSITIVE] OK, I can definitely help you with your claim status. May I have your name and a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And your name?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you for that, Ms. [PII], may I have your policy number or the claim number?
[CUSTOMER][NEUTRAL] The policy number is 252-7441.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And I have you here and I just need you to verify your date of birth, your mailing and email address on file.
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And this is for your claim, well, this is the only one, hold on one second, let me see why.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] It's under my husband.
[AGENT][NEUTRAL] Is your husband?
[CUSTOMER][NEUTRAL] Yes
[AGENT][NEUTRAL] OK. And um do you have the claim number?
[AGENT][NEUTRAL] Or the data service.
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] Or would it just be this
[CUSTOMER][NEUTRAL] It's 2 days service, 1:16 and 1:30.
[AGENT][NEUTRAL] Let see and one here it is.
[CUSTOMER][NEUTRAL] The
[AGENT][NEUTRAL] Is this the same? OK.
[AGENT][NEUTRAL] OK, and then what questions did you have in reference to the claim?
[CUSTOMER][NEUTRAL] So did something about the policy change because before it was like it's whatever the insurance pay out because when I looked at it, it's been processed and it's for $800 so 800 for both treatment days.
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] The [PII] and the [PII].
[AGENT][NEUTRAL] Are there more charges on here.
[AGENT][NEUTRAL] Yeah, the 82266 is like, looks like it's for [PII] and [PII].
[AGENT][NEUTRAL] So, for what it was.
[CUSTOMER][NEUTRAL] So what's the determination now because everything is changing, so that's not what it's been before, but OK, you're gonna explain to me.
[AGENT][NEUTRAL] Yes, I was. So,
[AGENT][NEUTRAL] What was billed is what was paid, what was paid. So like each code.
[AGENT][NEUTRAL] If you look on your, I don't know if it shows it on the explanation of benefits. Let me pull up your explanation of benefits. But for each code what was billed is what was paid like $210.86. That's what we paid $84. So we pay what we were billed for with the exception of, let me see what these two are right here.
[CUSTOMER][NEUTRAL] The chemo treatment?
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, so one of the calls was denied because it was the delivery of the radiation. So we only covered the like the actual administering of the medication, not like the treatment plans or X-rays related to it. So that's what that is saying, and then the other code.
[AGENT][NEUTRAL] Charges submitted are not covered by the policy contract. So all the calls were paid with the exception of those two, and it the amount that was billed is what was paid in full.
[CUSTOMER][NEUTRAL] OK, so, I need, I need you to kind of go back cause I'm confused cause it's a lot of stuff change and you know really explanation on why, because that's not what has been happening in the past. So if you could tell me the difference between
[CUSTOMER][NEUTRAL] What I see for 2 treatments in comparison to
[CUSTOMER][NEUTRAL] One of the, I'm trying to time my phone I'm driving to. So
[CUSTOMER][NEUTRAL] Back in
[CUSTOMER][NEGATIVE] February of last year. I only billed for one chemo treatment and y'all paid out more than that. Y'all paid out 4 times more than what you just paid out for 2. So I need a comparison to get an understanding, because I don't get it. What's the difference?
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Well, I can't, so the, uh, the only thing that I can explain is, I mean, I can go through the codes with you.
[AGENT][NEUTRAL] And what each code was charged.
[CUSTOMER][NEGATIVE] I don't know what the causes mean, and that doesn't help me because it's the same exact treatment. Same exact treatment, same doctor, same code, same everything from a year ago, but you paid out more. Same insurance, nothing has changed but the year.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] If you, OK.
[CUSTOMER][NEGATIVE] So it's the same exact from last year. Why are you all paying out different this year. So I need a comparison because you going over the codes mean nothing to me I'm not a medical person. So the codes don't mean anything, not to me it doesn't because I don't know what that means.
[CUSTOMER][NEGATIVE] And I can't
[AGENT][NEUTRAL] So, if you, OK.
[CUSTOMER][NEGATIVE] I'm on my way to work and I can't sit here and go code by code. And again code by code won't do anything to me because I want a comparison from what you paid out for the last 3 years and why we're not paying out the same this year.
[AGENT][NEUTRAL] OK, I understand.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So, if what was billed to us was $210.86 we paid $210.86 for everything that was charged.
[CUSTOMER][NEUTRAL] Who builds you?
[AGENT][NEUTRAL] University of Texas.
[CUSTOMER][NEUTRAL] Who, who does he?
[AGENT][NEUTRAL] You submitted the claim, what?
[CUSTOMER][NEGATIVE] Oh, you're just not gonna.
[AGENT][NEUTRAL] So I'm not trying to argue, I'm trying to help you see if a bill is $10 we can't because, ma'am, you won't allow me to see.
[CUSTOMER][NEUTRAL] You know, I mean,
[CUSTOMER][NEGATIVE] But you're not helping me because what I'm telling you is I was told before that you, because you keep telling me about building codes, you wouldn't believing I gave you.
[AGENT][NEUTRAL] Can I, can I, because
[AGENT][NEUTRAL] You're asking me about the money, so I'm trying to explain it to you.
[CUSTOMER][NEGATIVE] And I'm, but see here's my thing too is that you're not, you're not doing what I asked you. So let's if we want to go with respect here, let's be respectful because I asked you to pull up last year and compare and you won't do that. You keep shutting me down each time I ask you. Don't get a medium OG dummy.
[AGENT][NEUTRAL] I'm, I'm, I'm not
[AGENT][NEUTRAL] I'm not shutting you down.
[CUSTOMER][NEGATIVE] So I want you do what I ask, but you want me to listen to you, but you won't listen to me. That's the problem that I'm having right now cause I want to know the difference. You won't tell me the difference. You want to tell me what's built for you. That means nothing to me because I'm not a medical person.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So what's the data service that you would like me to search for you?
[CUSTOMER][NEUTRAL] That's one.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] For last
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] you're going through the thing.
[AGENT][NEUTRAL] Let me search your previous policy because this one,
[CUSTOMER][NEUTRAL] I ain't that one.
[AGENT][NEUTRAL] Oh, OK. Well, let me see, because the only other ones on here.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] I is that policy.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] So outside of the claim that we're speaking of, you have one claim that was processed [PII] for date of service, [PII].
[AGENT][NEUTRAL] The claim.
[CUSTOMER][NEUTRAL] That was for a skin, right?
[AGENT][NEUTRAL] Yes, ma'am. The claim after that.
[CUSTOMER][NEUTRAL] So that, that's not chemo.
[AGENT][NEUTRAL] I'm just going through the claims that we've processed because there's nothing here for [PII]. So the claim after that,
[CUSTOMER][NEUTRAL] What?
[AGENT][NEUTRAL] The climate
[CUSTOMER][NEGATIVE] It's not on this policy, it's on the previous policy. Oh my [PII], we cannot do this simple.
[AGENT][NEUTRAL] Well, that's what I just
[AGENT][NEUTRAL] Ma'am, I'm, I'm not trying to argue, I'm just trying to give you the answer. I just said, well, let me look at the previous policy and you said it's this one. So I'm just going through the ones on here.
[CUSTOMER][NEUTRAL] No, no, no, no, that's not what I said. I said it's the same policy, but go ahead. It's, it's the same policy as the last 3 years is what's exactly what I said.
[CUSTOMER][NEUTRAL] I know you're not gonna see it on this policy because this policy wasn't affected since [PII], so.
[AGENT][NEUTRAL] OK, so let me go back to the previous policy as I was. Hold on one second.
[CUSTOMER][NEUTRAL] No I
[AGENT][NEUTRAL] OK, [PII] $11,795.52.
[CUSTOMER][NEUTRAL] Yes, 223, 24.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So that's what, OK, so what I'm trying to explain to you is this chemo treatment was 11, that's the total that it was $11,795.52. On the chemo treatments that I was trying to go over with you, there's no charges that's that much.
[AGENT][NEUTRAL] So what we were charged, we paid. So I was trying to explain to you, there were charges for like $200. We paid $200. Like for this one, it's $11,000 we pay $11,000. So that's all I was trying to explain to you, was that we paid exactly what we were billed for in full. The difference is the amount that was charged, and that's all I was trying to explain to you, ma'am.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEGATIVE] For 2 treatments. It was more that so what was told to me before was that you guys pay out what the insurance pays. It's exactly what was told to me, and that's what's happened for the last 2 years. So they changed this year because that's not what the insurance pays.
[AGENT][NEUTRAL] Ma'am, but the difference is what was charged on [PII], we were billed, we were charged $11,795.52 and that is what we paid to you.
[CUSTOMER][NEGATIVE] And both of these, each, each was $5000. So what are you talking about? I read it before I sent it. Both of these bills individually $5000. So you're coming up with $800. So if you were billed for $11,000 then this one was 5. Why didn't you pay that?
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK. So
[AGENT][NEUTRAL] So then the people that you're really upset with and need to speak with is the people that make the charges, the provider, we only bill what we're, we only pay what we're billed. The charges come from the provider, so if you feel like there's a difference in what you're being charged, you need to speak with the hospital. We're the insurance company, we just pay.
[AGENT][NEGATIVE] We don't have anything to do with what they charge.
[CUSTOMER][NEUTRAL] No, you, but what I was told from your part, not from anyone else, is that whatever this bill is what you guys pay and that's what I've been doing. So can you provide whatever that is in writing so I know what I'm looking for when I send you some more stuff. And I don't mean the manual.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Would you like me to send you?
[CUSTOMER][NEUTRAL] I want detail exactly what you look at and what you pay, not the general information about what allotment there is available per year. That's not what I want. I want exactly what you just got to say. How was the deal, what codes and everything. I want to see all of that. So that when I look at the EOB I can see it again.
[AGENT][NEUTRAL] That's
[CUSTOMER][NEGATIVE] Because I don't, that's not right. Because you pay even without that one the month, the treatment before that was $4000 which was exactly what was on the EOB and on the itemized I paid it, but now all of a sudden it's on the itemized and the EOB you're not paying it.
[CUSTOMER][NEUTRAL] And you won't tell me the difference.
[AGENT][NEUTRAL] Ma'am, I've explained to you the difference in detail. I
[AGENT][NEUTRAL] Your bill, the bills that you sent in show.
[CUSTOMER][NEUTRAL] What bill, what exactly what bill are you talking about? Cause you keep saying what is deal to you, what's bill to you, what exactly, specifically. So compare the two, because like I said, if you don't want to do that one, so now I, I'm even later for work. Let's pull over so I can give you another day that you can pull up that doesn't have 11,000.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Ma'am, can you, can
[CUSTOMER][NEGATIVE] That may have 5000 and it's the same thing that's on the ELB that I've already sent you and I sent you to equal to 10,000. So if that's not the case, I was so without one. Because you're not listening to me. I heard everything that you said, but I'm asking you more specifically, you won't give it to me, you keep giving me these calls. That doesn't mean that to me.
[AGENT][NEUTRAL] Ms. [PII].
[CUSTOMER][NEGATIVE] I'm, I'm looking at the difference. I see what's sent to you. I know what I sent to you. I send it multiple times because you give me a hard time because one agent tells me one thing, another agent tells me another thing, and I just sit here and keep going back and forth, and it makes no sense.
[AGENT][NEUTRAL] I
[CUSTOMER][POSITIVE] But I, I see a big gigantic difference from last year to this year.
[AGENT][NEUTRAL] OK, so this is what I'll do. Let me do this for you.
[AGENT][NEUTRAL] Let me do this for you. I'll go ahead and get a claims examiner on the line, the people who process the claim, and they can go ahead and go more in detail with you about your claim. Would you like to speak with the claims examiner?
[CUSTOMER][POSITIVE] Yes, thank you.
[AGENT][NEUTRAL] OK, hold on one moment, thanks for calling APL.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEGATIVE] I'm not doing that. Like, I'm just not.
[CUSTOMER][NEUTRAL] Transferring.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Good morning. Thank you for calling American Public Life. This is [PII]. How may I help you?
[AGENT][NEUTRAL] Hey [PII], this is [PII] on the care team. How are you?
[CUSTOMER][POSITIVE] I'm just fine, thank you.
[AGENT][POSITIVE] That's good. Um, I have a
[AGENT][NEGATIVE] Insured on the other line. She's upset. She's just getting herself upset. Basically, she has a cancer policy. There's two different cancer policies, um.
[AGENT][NEUTRAL] She wants to know why one claim was paid 11,000 versus 800. We paid the actual charges. She's not understanding what actual charges are. I'm trying to explain to her, we paid what we were billed, um, but she just keeps getting herself upset, saying that she wants me to compare and um tell me which bills or tell her which bills, um, so she just needs to speak with someone in claims more in depth with her, uh, OK.
[CUSTOMER][NEUTRAL] OK, what is her policy number?
[AGENT][NEUTRAL] So the first one, I'll give you the one for the 11,000, it's 242-6704.
[CUSTOMER][NEUTRAL] And her name is [PII].
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, give me one.
[AGENT][NEUTRAL] And it's OK.
[CUSTOMER][NEUTRAL] And that is her GC 14.
[CUSTOMER][NEUTRAL] And then she has the GC 7002. Is that the claim that she's on? I, I don't know.
[AGENT][NEUTRAL] Well, hold on. So the, the, OK, wait, so the GC 14, we're looking at claim number 3422156, I'm sorry, 3422156 is under part two.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, this is her husband, correct? OK, hold on here. She, I think I.
[AGENT][NEUTRAL] Yes. Mhm.
[CUSTOMER][NEUTRAL] She gets very.
[CUSTOMER][NEUTRAL] Hold on.
[CUSTOMER][NEUTRAL] I like I'm, I'm pulling things up.
[CUSTOMER][NEUTRAL] So this is on [PII]. OK, now hold on, let me get the other one up.
[CUSTOMER][NEGATIVE] I think I have spoke with her before. She's gets mad very easily.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And you can't explain anything to her because she's always very
[AGENT][NEUTRAL] She's just ready.
[AGENT][NEUTRAL] I just have to say, OK.
[AGENT][NEUTRAL] I, I
[CUSTOMER][NEUTRAL] I know.
[CUSTOMER][NEUTRAL] I'm sorry, let me, I want to pull things up before I
[AGENT][POSITIVE] Oh no, you're fine. Yes, get all the ducks to the row.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] No, I don't think I spoke with her. She's not the one I'm thinking of, thank goodness. OK, so hold on here, let me.
[CUSTOMER][NEUTRAL] So which um which client? uh-huh.
[AGENT][NEUTRAL] So under the the GC 7002?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] We're looking at that last claim, um 356-660-9.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So her argument is why is this one being paid 82266 and the other one on the other policy was paid 11,000 and I'm trying to explain to her that one was billed for 11,000, this one was billed for 800, so she's not um understanding that I explained it as simple as I could. Um she's just
[CUSTOMER][NEUTRAL] What, what, OK, so.
[CUSTOMER][NEUTRAL] 8240 because she maxed out. That's why it was 82, um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And she's wanting to know why she only received 822.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Versus the 11,000 versus the 5000 on the other policies, but that's not what we were built on this one.
[CUSTOMER][NEUTRAL] And let me
[CUSTOMER][NEUTRAL] Because each bill is different and.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] It's OK. Let me, let me get this, these claims pulled up and everything so that I'll be ready for her. Hold on.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I'm gonna pull up that policy.
[CUSTOMER][NEUTRAL] Now actual charges is the, we use the um the copay, deductible and co-insurance amount to get the actual charges. So that is the, just for future reference, that's how they get uh determine the actual charge charges. We don't use the billed amount.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] We use what the copay, we plug in the copay, we add the copay deductible and charged amount together and that is the amount that we're gonna pay. So that's just a future reference for you, um, just to give you a heads up, I'm still pulling her [PII]. I'm looking at her mail, so give me just a minute.
[AGENT][NEUTRAL] The actual
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Am I right?
[CUSTOMER][NEGATIVE] Not even on the right one, hold on.
[CUSTOMER][NEUTRAL] OK, you can go ahead and transfer her if I have to. I can put her on hold so I can review her file further, but go ahead and transfer her. That's fine.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] Hello, Mrs. [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Thank you so much for holding. I have [PII] on the line and she'll be assisting you further, OK?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Hello, Ms. [PII]