How To Get Medical Insurance Claims Paid. Don’t Get Denied!

by Kosmo on 2011-09-114

I can think of a million things I’d rather do than sort out my medical bills and payment issues. But it’s a common complaint. If you’re making an insurance claim, how many times have you had this dialogue with your friendly neighborhood insurance agent?

Customer: I’d like to check on the status of my claims please.
Client Rep: All the information we need is not in the documentation you sent us.

Customer: What is it this time?
Client Rep: The clinical codes are missing.

Customer: I just had the documentation sent 2 weeks ago.
Client Rep: Okay one of the clinical codes is not valid in our system, it’s a stale code and you need the new one used for this year.

Customer: Can you just ignore that one code in the receipt?
Client Rep: No. Also, there’s another code that has 3 digits instead of 4. We need it to be 4 digits or we can’t process your claim.

Customer: Will fixing this matter expedite the processing of my claim?
Client Rep: Well, if you’re lucky, we’ll send it to the adjusters in 30 days. Then you can wait another 30 days for the adjusters to review them. If we notice any more missing information we’ll stall your claim and have you start over. If we wake up on the right side of our beds tomorrow, we may send it to rapid resolution, which will only take us just 45 days instead of 60 to send you your $10 reimbursement.

It’s often the case that every time you get on the phone, a different representative or agent is at the end of the line, needing to be briefed all over again. Try calling your rep and you’ll quickly realize where voice mail hell originated from. So what can you do to get your health insurance claims paid? Try these tips:

Tips To Get Your Health Insurance Claims Paid or Dealt With

1. Ask yourself: is the insurance company right?

Gasp! Sometimes a claim denial or delay is completely justified. The first thing you’ll want to do is make sure you understand your coverage. Your insurance policy is a contract, and as such, binds both parties to the terms.

There are several legitimate reasons for denial. These include:

Exclusions – Your policy may have exclusions related to pre-existing conditions. It may not cover experimental treatments. It may place limits on organ transplants. Study your policy details and make sure you understand what is covered.

Maximum number of visits – Your policy may restrict the number of visits to specific types of medical providers. For example, it’s quite common to limit the number of visits to a chiropractor.

Frequency of visits – Many policies cover annual exams. In some cases, this means one exam per calendar year. In theory, you could have one exam in late December and another in early January, and both could be covered. However, some policies are more literal, only covering the exams if they are more than 365 days apart.

2. Ask yourself: did the doctor’s office make a mistake?

If my doctor’s office bills my insurance company for a hysterectomy, I would expect the insurance company to immediately deny the claim. Why? Since I’m a man, it would be highly unusual to undergo a surgery to remove my uterus.

That’s an extreme example, but it’s important to realize that providers use codes when they charge insurance providers. It’s not that difficult to inadvertently use the wrong code and attempt to charge the insurance company for the wrong service. Check the explanation of benefits — does it correctly describe the service you received?

The medical providers usually catch these errors, but sometimes they don’t. It’s also common to see duplicate charges due to a provider accidentally submitting the same claim twice.

3. Communicate your case well.

If you are sure that the charge is correct and that coverage exists for the service, it’s time to contact your insurance company.

My preference is to use email, or the insurance company’s web site, to communicate the issue to them. Writing has several advantages over a phone call. It allows you to fully communicate your thoughts without being interrupted, compose your thoughts before communicating, and link to relevant documentation. Additionally, if the person taking initial ownership of your call can’t solve it, she can forward it to another employee and that employee will have a description of the problem in your own words.

If you make initial contact via phone, make sure you have the details in front of you. Have the explanation of benefits (EOB), the related doctor’s bill, and any other information you need. Being able to immediately reference important details will make the process go much more smoothly.

Has it been covered before? My insurance plan covers “well child” visits. There is no deductible or co-pay for these visits. After one visit for my son, I noticed that part of the cost of immunizations was listed as being my responsibility. I made initial contact on my insurance company’s web site, but was then asked to call to discuss in more detail. During the subsequent discussion, I was told that the actual doctor visit and the drugs used in the immunization were covered, but not the actual labor related to the immunization.

In other words, the charge was related to the cost of the nurses administering the immunizations. I had the insurance company’s web site in front of me, and pulled up an EOB from a previous well child visit. It covered all of the costs related to that visit, including immunizations. I pointed this out, giving the date of the EOB. The employee agreed to look into it, and a few days later, the charges were covered.

If you notice that something that has been routinely covered in the past is not being covered now, point this out. The insurance company employee may be able to determine the problem by comparing the older EOB to the new one.

4. Try customer service roulette.

I’d like to say that every customer service representative you talk to is going to do everything within their power to help you. Unfortunately, that’s not always the case. Sometimes you’re talking with someone who doesn’t understand the issue or is having a bad day.

You can confront the person and try to change their attitude, but this can often be an exercise in futility. In these cases, I usually cut my losses and play what I call “customer service roulette”. I make up a reason for cutting the call short (need to run to an appointment), politely thank the person for assisting, and say that I’ll call back.

Then, I call back, in hopes of getting a better representative. You don’t want to call back immediately, as the call might go the the person you just talked to. Wait a half hour and try again.

Tip: keep your tone civil. Yelling at the customer service representative or insulting them is not likely to make them work harder on your behalf. Instead, remain calm and polite. When I encounter a situation where there is a clear difference of opinion, my general approach is to start by saying “My understanding of the situation is …” and then after explaining, concluding with “… What am I missing?” This still has the effect of forcing the person to find a specific reason for the denial, but doesn’t put them on the defensive as much as something like “Why can’t you idiots understand!”

No matter how upset you get, NEVER resort to threats of physical violence. There have been situations where people have been arrested for making threatening comments over the phone.

Document every single correspondence between you and the company. Take down the names of all personnel you speak with and the date/time of correspondence (for later reference).

5. Know when to seek further escalation.

If your customer service roulette doesn’t pay off, it’s time to take the next step and escalate to a supervisor. Supervisors often have a bit more discretion when it comes to matters that fall within a gray area.

If this still fails to resolve the issue, it’s time to talk with your agent and have him intercede on your behalf. Agents are often paid on a commission basis, so he has a vested interest in keeping you as a customer. If a claim dispute causes you to leave, that’s money out of his pocket.

If you have insurance through your employer, you won’t have an agent. However, you will have an administrator for the plan. If you feel that the insurance company is violating the terms of the insurance contract, discuss this with your company’s plan administrator. While you might not have much influence with the insurance company, the plan administrator does — since she has the power to choose a different insurance provider for the whole company.

If you’ve exhausted all of these avenues, then it’s time to appeal the denial. The appeals process will vary from company to company, so you’ll want to research the specifics of your insurance company’s process.

6. File a complaint.

If you lose your appeal, then it’s time to work outside the insurance company’s processes. If you are still convinced that the company is incorrectly denying your claim, you may file a complaint with your state’s department of insurance. The name of the organization varies slightly from state to state, as do the precise details of the group’s operations. When you file a complaint with the department of insurance, the insurance company has a specified number of days to respond in writing or face financial penalties. Insurance companies take these complaints very seriously.

7. Lawyer up.

The last resort is to file a lawsuit against the insurance company. This may not be a practical option in some cases. If you’re fighting over the denial of a $50 charge, it may not be worth your time and money to engage a lawyer and go through a trial. However, if the dispute centers around a heart transplant costing tens of thousands of dollars, hiring a lawyer may make a lot more sense.

In Summary

It can be a frustrating experience if you pursue your insurance concerns carelessly. I’m being snarky here, but a few other things may help: maybe you should suck up to the representatives. Maybe offer them free tickets to the next sports game 😉 (okay, just kidding). Basically, be nice and don’t lose your cool.

Or how about the best option of all? Don’t ever get sick, get into an accident, die, burn your house down or be a crime victim. That way, you won’t have to wrestle with insurance.

Kosmo has been employed in the insurance industry since 1997. In his spare time, he runs The Soap Boxers. He is also the author of Mountains, Meadows, and Chasms, a collection of short stories.

Created September 5, 2006. Updated September 11, 2011. Copyright © 2011 The Digerati Life. All Rights Reserved.

{ 4 comments… read them below or add one }

JGV December 9, 2008 at 9:41 pm

Missing this and that on your insurance claim can really make one sick to the stomach.

I like that advice on dealing with the problem especially the one that says you have to document everything. That is an excellent thing to do. Because now you will have the tools and evidence of your communication.

From what I’ve heard, these things happen for a reason. Some insurers and adjusters have this quota for each of the case officers. Now if the officer goes over the quota, then they have to stall the process so they can charge for the next quarter or whatever the period they are using.

For instance, the officer is dealing with one thousand short and long term disabilities, and on average getting paid 2000.00 dollars a month, that would be basically 2 million dollars of pay out. If they are over the threshold of pay outs or the incentive to get bonuses for the officers, they do stall and pay on the next cycle.

Just what i heard.

Life Insurance

JGV December 9, 2008 at 9:42 pm

BTW, Good luck to everyone and I hope nobody ends up losing sleep over these things.

Kenneth Ford September 20, 2010 at 2:48 pm

I would consider changing to a PPO based HSA plan, then you don’t have to worry about out of network issues.

Paulo Roxcy November 4, 2010 at 4:53 am

Insurance is vital in modern day living. You need to make sure that those you leave behind will be supported.

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