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As we all age, finances only get steadily more complicated as assets and debts rise alongside life’s own complexities. These days, I’m not losing sleep over debts or credit lines. These days, I’ve been grappling with insurance claims. The reason for this is that the last few years, my family and I have been seeking and receiving rather more exotic medical services than the usual HMO type checkups normally covered by insurance. Seeing out-of-network providers usually means paying out of pocket first then trying to get your money back from insurance later. That’s the pit I’m in right now — we racked up out-of-network claims, and the job has fallen upon me to deal with the insurance bureaucracy to get back some of my dough.
I already have a weekly routine with our friendly neighborhood insurance agent, except that the agent changes every week. After going through the requisite voice mail system, it goes like this:
Me: I’d like to check on the status of my claims please.
Rep: All the information we need is not in the documentation you sent us.
Me: What is it this time?
Rep: The clinical codes are missing.
Me: I just had the documentation sent 2 weeks ago.
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.
Me: Can you just ignore that one code in the receipt?
Rep: No.
Me: Is that all that’s wrong?
Rep: 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.
Me: Is there any way you can expedite the processing of my claim?
Rep: 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.
And when the benefits plan states that out-of-network coverage is 70%, it really means that the insurance company only considers 50% of the total as the basis for the claim, then applies the %70 coverage against that. Hence, insurance REALLY just covers 35% of my bills, not the advertised 70%. In effect, this insurance thing only works fine if you stay “in network” and with a cookie cutter HMO to avoid having to file claims yourself. I am beginning to think that PPOs are a rip off especially after you consider the sky high premiums. Why do I stay with a PPO? It’s a matter of trusting the medical providers and I’d much rather be able to select the experts I’m comfortable with. So I’ve done the trade off and am living with a necessary evil here.
Here are some suggestions to deal with your insurance company:
- Suck up to the representatives. Maybe offer them free tickets to the next sports game. Basically, be nice and don’t lose your cool. If that doesn’t work…
- 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. Then go on appeal. If that doesn’t work, try, try again.
- Best option of all, don’t ever get sick, get into an accident, die, burn your house down or be a crime victim.
< Credit: newstarget.com >
