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Dealing with Health Insurance Companies, in general

The last post in this topic was posted 2968 days ago. 


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So I've seen a lot of posts lately concerning medical collections, and I'd say a solid 80% of them involve uncooperative insurance companies. So, being a seasoned health insurance vet (at the ripe old age of 21- complicated pregnancies will teach you lots), I thought I'd share what I've learned in how best to work the system, and what some of the governing laws are.


Below you'll find:

-stopping problems before they start

-how to CYA and build a papertrail, since you just can't get around calling

-Prompt Payment Laws

-Common Insurance/Doctor's office scams (or, whose fault is this, the insurer, or the doctor???)

-when they just won't cooperate...


Stopping Problems Before They Start

I'd say a solid 99% of problems people have with insurance companies are simple misunderstandings of what is and is not legitimately covered, and at what levels benefits should be paid. The time to ask questions about coverage, authorization procedures, etc. is BEFORE you see the specialist, and BEFORE you have expensive tests, surgeries, and procedures performed.


Your insurance is a contract between you and your insurance carrier. Your doctor's office staff will hopefully prove helpful and competent in navigating the pre-approval/authorization process, but it is ultimately YOUR responsibility to understand what your particular carrier requires (and believe me, they can get particular) and make sure your physician and his/her office staff jump through any "necessary" hoops. The corrollary to this is, that if your insurance doesn't pay, delays payment, or makes a retroactive denial, you're still responsible to remit timely payment to your doctor. It's not their problem that your insurance company is being difficult, you still agreed to pay for the services rendered. Hopefully though, the doctor's office can prove to be one of your most valuable assets in dealing with the insurance company, so be polite, and keep them informed. The physician's office/hospital is much more likely to be helpful, understanding, and amenable to temporary payment arrangements if you are proactive and explain the problem and solicit help before you've gotten three "pay now or else" letters.


The best way to avoid problems with your insurance company, is to read and understand your member agreement/explanation of benefits. Member agreements are long and tedious. Ours is 400 pages. But, it goes into excrutiating detail on what is and is not covered, what might be covered under certain circumstance (read: you make a real pest of yourself), and your level of coverage for different types of doctor's visits, hospital stays, etc. You'll also want to be very familiar with your maximum out of pocket limit for the year.


Insurance companies make errors in benefits checks all the time (ie, pay 80% instead of 90%). You'll want to be able to spot those errors quickly, and reference the exact part of your member agreement that proves your case.


Insurance companies commonly do "first round denials" all the time for covered benefits, just to see if you're willing to put up a fight. Again, you'll want to be able to reference the exact part of your member agreement that indentifies their error.


So read your member agreement, know it, and understand it. Better now than later. Trust me.


Building a Papertrail, and Covering your Toushie

When dealing with health insurance companies, your papertrail is every bit as important as it is with your credit disputes. The problem is, with health insurance companies you really can't get around calling. I can't tell you how many times I've called to get a confirmation of coverage, or interpretation of coverage. When these promises turned out to be incorrect, I would call back to find that "there's no record of there ever having been a Ms. "x" at ext xxxx." So, here's the process I've adopted to solve that problem:


1) Record the phone call if you can. If you can't, take copious notes on the conversation, or write a reasonable summary of the conversation RIGHT AFTER you hang up.

2) Immediately upon getting through to customer service, ask for the rep's name and ext#. That freaks them out.

3) Don't assume anything. Confirm everything, three times. If you get ambiguous statements, ask for clarifications. I use this statement, "I understand you to say _______. Is that correct?" If they won't commit to anything, or keep talking in circles, make a huge note of that in your summary. Also, write down EVERY version of what you were told. It's not at all unusual for them to answer the same question three DIFFERENT ways. If you get a different answer every time you ask the same question, you want to have notes of this. Also, if you receive authorization for a procedure, demand an authorization number. If they absolutely refuse to provide this, make a note of this.

4) After you get off the phone, write a letter to your insurance company, to be mailed CMRRR. Give the name and ext# of who you talked to, and a summary of the conversation. Explain that the insurance company has 5 days from the confirmed receipt of your letter to clarify or make changes their interpretation of your member contract. If you received an ambigious answer from the CSR on the phone, they have 5 days to clarify. If "the powers that be" believe a mistake has been made, they have 5 days to contact you and inform you of the error. Explain that if you do not hear from them, you will accept that as their agreement that the statements made in your letter are correct. Remember, you HAVE to do the CMRRR. Nothing else will do in this situation.


Written notes aren't the only thing you need to save in relation to your insurance. You need to save EVERYTHING medical that you receive, right down to the envelops. It goes without saying that you need to save every explanation of benefits from the insurance company, along with approval/denial letters. However, you also need to keep all receipts you receive from the doctor's office. Believe me, if it ever goes into dispute whether you paid your co-pay, or even had an appointment on a day the health insurance company believes is a fraudulent claim, you need to be able to prove your case. It doesn't have to be a big, fancy filing system. Infact, we just have a drawer where everything medical goes. That way, if we need it, we've got it.


Prompt Payment Laws

In some states, there are laws governing how quickly your insurer must remit payment for claims received. I'm too lazy to look up and list all the states myself, but I think there's 17 (or something like that) that have these laws. The laws vary slightly from state to state, but basically, the insurer has 30(+5 for mailing) days once they are in receipt of a "clean" (readL properly filed) claim to "act" on it, either by remitting payment, or providing a "good faith reason for denial". For claims purposes, the insurer is considered to have received the claim 5 days from the postmark, triggering the 30+5 day period.


"Good faith reason for denial" means exactly what you'd think. Either the claim has to be found to be fraudulent, or the patient inelligible for benefits at the time services were rendered, or the benefits must be explicitly not covered in the member contract. If claims are frivolously denied (ie, denial for benefits that are unquestionably covered) as is often done to test the resolve of the member, the insurer is not only guilty of breach of contract, but violation of Prompt Payment Laws as well.


Common "good faith reasons for denial" include: verification of insurer liability (a form you fill out certifying that you are who you say you are, and listing any other health insurance you may have), requests for more information, or an improperly submitted claim. Now, some of these are often stall tactics, but they are legal stall tactics. Upon receipt of the necessary documentation, or fulfillment of whatever they (reasonably and legally) asked of you, they have 30 days to remit payment.


If you continue to have problems with delayed claims, and/or you believe the insurer is frivolously denying your claims, you'll need to escalate your efforts.


Common Insurer and Provider Scams

It's no secret that the health industry is rampant with scams. Infact, I marvel everyday at the stories I hear from CBers about their health care billing experiences. Here's what they'll try to do to pull the wool over your eyes:


Doctor's offices

Doctor's offices will commonly send you to collections before your insurance company has had a reasonable amount of time to pay, balance bill (bill you for the portion of the bill your insurer didn't pay), or just plain not file insurance claims properly, and then come after you when the insurance company doesn't pay.


While insurance is a contract between the consumer and the insurer, there is also a contract in place between the doctor and the insurer IF YOU ARE SEEING AN IN-NETWORK PHYSICIAN!!! The doctors have agreed to contracted rates. They have agreed that if they don't file claims properly, or if they fail to receive proper authorization from the insurer, then they get nothing. That's what they agreed to in becoming "participating" physicians.


So quite often, when your doctor's office comes after you because your insurer hasn't paid part of the bill, or the insurer has refused the claim, it's between the doctor and the insurer. It has nothing to do. In my experience, if you are on top of things and call the insurance company and explain what has happened, they'll be more than delighted to call the doctor's office and read the riot act for you. This is where it gets really important to have an excellent paper trail. The insurer is required to mail you an "explanation of benefits" for any claims they receive, explaining what is and isn't covered, and why. If you've gotta piece of paper saying the doctor's office filed a claim wrong, and is entitled to nothing, and a bill from the doctor for what the insurer denied, it's pretty obvious what's going on.


Insurers keep track of how often their providers run scams like this, and will take care of reporting them to the appropriate authorities for you. If the physician continues billing you after the insurer has called and "handled" it, that looks bad too. If a doctor displays a pattern of this sort of unethical billing behavior, they will be dropped from the network and fined by the insurer. The only way the insurer will ever know there's a problem, however, is if you tell them.


So, if you believe you're being fraudulently billed by a doctor, don't even call their office to straighten it out. Call the insurer and save yourself a few phone calls and a lot of irratation.


Insurance Companies

We all know what the insurance companies like to do...deny claims they should unquestionably pay, and stall payment as long as humanly possible. They also really like to tell you one thing on the phone, and then conviniently forget when it comes time to pay as promised.


The single biggest issue, however, is telling you it's a physician's problem and telling you to handle it with them when you're dealing with an in-network provider. If you see an in-network provider, and encounter a billing/collections issue, then it IS UNQUESTIONABLY the insurer's responsibility to handle. You went to see a participating provider precisely to avoid these types of games. If insurance company won't handle the problem with the doctor/hospital themselves, then tell them you don't care whose fault it is, you're just going to start suing people, and will let them figure out who dropped the ball in discovery. Or report them to the Insurance Commissioner...


Then follow through.


When they just won't cooperate...

Sometimes, no matter what you try, the terrorists just won't cooperate. Here's what I recommend:


Contact your State's Department of Insurance/Insurance Commissioner!!!!!!!


They may brush you off, tell you 50 different stories about how something should be covered, or tell you that your dispute with the billing of an in-network provider is between you and them. Spin their wheels for awhile and then tell them that you're giving them one final opportunity to do what is mandated by law before you contact the insurance commissioner. This is where you'll really want to have them on tape; they'll go ABSOLUTELY NUTS!!!


They'll tell you that it's unnecessary, that this is between you and them, and that you're wasting your time. Well, it takes about 15 minutes to file a complaint with the DOI. You probably spent twice that long on hold.


They man give you the run around, but you'll find the dance they do for the insurance commissioner absolutely incredible! If the DOI says "Jump!", the insurance company will ask when they can come down. In my experience, it takes about 2 weeks for complaints to be handled, from the time I raise the flag on the mailbox, until I get the results. It's definitely an expiditious process in my experience.


Remember, the insurance company hates nothing like getting complaints to the DOI.


Other things you can try, include going through your company's HR person, or insurance broker (if you purchased privately). Remember, when you have problems, it's their job to resolve them. Also, a company's HR person will usually have a contact that can handle the problem for you immediately. You should also be familiar with your state's employment laws; if you are paying all or part of the premium for health insurance for your employer, they can be held secondarily liable for the actions of the insurance company they effectively forced you to buy from.



This is by no means to be considered legal advice, or an exhaustive resource. Insurance laws vary widely by state. These statements are general in nature. While I'm extremely familiar with the insurance laws in North Carolina, I frankly couldn't care much less about what the laws are in other states, and don't have time to research everything right now. Perhaps some of us could get together, and each compile a list of the laws for our state...


I'm sure I've left stuff out, and that you'll have questions. Ask away, and I will do my very best to help you out![/size]

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You know Joe, if you had serious nipple chaffing problems, got a trumped up diagnosis from your doc, and had him prescribe this for his "treatment plan" to correct the condition...


...maybe you could get your nipple guards covered as a prosthetic device????


And yes, I've already figured out how to force them to pay for my tummy tuck :twisted: ;) ...


It's not for cosmetic purposes...it's due to the injury this baby caused to my waistline...and mental health :8) .


I'll keep ya updated...

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So it just occurred to me that I left out something of extreme importance in the original post:


Familiarizing yourself with your insurance company's complaint procedures.


It is absolutely vital that you understand what these procedures are, so that you don't inadvertently end up using all your allowed disputes for a particular claim before you realize it.


Any time your insurance company makes a decision you don't like (denies coverage, etc.), you can dispute the decision. Usually, you have 30 days from your receipt of the explanation of benefits from a claim, or notice of a refusal to cover a requested procedure to lodge a complaint.


Of course, this varies among insurers, but is pretty "industry standard".


If you miss that 30 day window, you're SOL.


While it is important, and may prove beneficial to call and inquire about the issue (especially if you're familiar with your member contract and know that the denial was unquestionably wrong), be absolutely explicit in your refusal to allow the CSR to lodge the complaint for you. If they don't ask, make sure you tell them that you don't want to dispute formally yet.


If they understand the problem, they can order the claim to be paid without your lodging a formal complaint. Some are more amenable to this than others.


Remember, you want to put your formal complaint in writing, citing all the reasons you feel the denial was wrong. You want to be sure that you communicate exactly what the problem is, and that you know what your rights are, before your appeals can run out.


It's vitally important that you not allow them to lodge formal complaints/appeals over the phone, b/c typically, you will only get two rounds of disputes before you have to go in front of a panel to plead your case. Costing you LOTS of time and money. Again, this is based on what I've observed among several insurers in my state, and could be considered industry standard. But, you need to be familiar with exactly what your insurer's process is. This information is at best, general.


They're counting on your calling to discuss the issue atleast twice, and allowing them to lodge complaints on your behalf really removes your best avenues for appeal and resolution.


If you get through the two rounds of disputes, your final appeal is in front of a medical board. Usually, state laws sanction that these are board certified doctors, affiliated with the insurance company in no way.


When you go in front of the panel, remember that while these are doctors, and you need to present a strong medical basis for the treatment you are requesting, the panel's job is to determine whether or not the insurer is contractually obligated to remit benefits in your case. So you need to show them exactly where it says in your member contract that you are entitled to said benefits, or that they are being otherwise unfair in their denial. If a treatment is specifically excluded, it's probably not worth going. Ambiguous statements in your member contract, however, are definately worth arguing for in your favor.


Again, these are just generalities. Different contracts have different provisions. Remember this, though:

-You have a limited number of disputes/appeals, and time in which to file them

-Be careful on the phone, that you don't unwittingly use all your complaints

-If it gets to the medical review board, it's still all about contract interpretation.


Good luck!!!

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Brilliant post Char ... too bad this could not be published - I'd love handing this out to folks in the office I work in !


alas, mental health claims won't get you the tummy tuck - your insurance company really doesn't care about your psyche - as long as you can work to pay their premiums ! . insurance WILL pay for a panniculectomy but not the full blown abdominoplasty - and I'd be willing to bet you are happy you are not a condidate for a panniculectomy !

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Brilliant post Char ... too bad this could not be published - I'd love handing this out to folks in the office I work in !


alas, mental health claims won't get you the tummy tuck  - your insurance company really doesn't care about your psyche - as long as you can work to pay their premiums ! .  insurance WILL pay for a panniculectomy  but not the full blown abdominoplasty - and I'd be willing to bet you are happy you are not a condidate for a panniculectomy !

If you wanna print this out and hand it around that's fine by me, as long as everybody understands that this is general in nature, and laws vary from state to state.


The joke about getting published is cute, too. I studied microbiology in school, and an old prof called me not too long ago inquiring as to why he hadn't seen me 'published' yet (my name on a journal article). Ofcourse, we all know it's because I take my job keeping the homefront strong very seriously :wink: .


So maybe I'm going about this all wrong...maybe I should start writing crappy poetry or something and try to get 'published' that way. :)



I don't work. I stay home. I'm too embarrassed to leave the house b/c of my expanding waistline...or is it b/c I'm on house arrest...I forget :P .


Yeah, and I'm definitely not a candidate for body recontouring yet...that's probably a couple kids off .

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wowOwowwwwwwww Char,


You KNOW I'm moving this to the consumer protection forum (leaving a link here too) with a thousand thank yous!!!!!!! I read the other night while searching around with you on the related thread that only one state, Idaho, did not have any prompt pay laws -- so I'll dig up those links and add them to this awesome resource.


I'm dragging out all my "ings" for you:


I'm bowing to you, flying with ya, singing, dancing, swaying AND flicking my bic!!!!!!!!



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As long as it goes up with the ENORMOUS caveat that this is general info...


...I'd hate for someone to act on this and then be upset b/c that's not how it worked with their insurer.


But seriously, a group of us should get together and compile the insurance laws and put them in the state threads already there.


See, it's not always the scummy CAs, it's the $%^&*-ing insurance company!!!


If my insurance company has "special handling", I'm sure I'm in it. I know my file is "flagged" anyway...not that that stopped them from doing stupid stuff :) .

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ok, I added "in general" to your title -- you've got it covered in the text as well. Nodding and agreeing on the state specifics, I hope everyone does the same -- that was the idea of this forum!!!!!!!!


It's an important thread, there are so many medical postings and collections and with the Hipaa series thrown into the mix, there are a lot of misconceptions too -- like the bill isn't valid if your insurance company didn't pay, or that there is a requirement that insurance be billed, or that service providers have to be paid directly by the company, blah blah blah.


Can't just point to the insurance company and dodge personal responsibility (not mine, shrug shrug) when you've not pursued the options they give you for resolution and that's between you and the insurance company, not you and the service provider or CA.


This thread is like the missing link and the time to know about it is before something goes to collection so you can use it effectively -- proactive posting, I say!!!!!!



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Great thread, thanks. :lol:


Is there a common state office, similar to the Insurance Commissioner, to help you if your problem is with the doctor's office? I don't know how much good using the insurance company would be for me, because it is health coverage through auto insurance (after a car accident), not a regular health insurance plan.


It would be nice to have someone with familiarity with these issues covering my back as I try to nail the health care provider for failing to send a bill/claim to the insurance and then sending me to collections and messing up my CR! A general consumer rights office, or one specifically for health care issues? Or would the insurance office cover something like this?

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I've worked in the Medical billing/collections field for over 10 years now (ok, I won't go higher than that because I don't want to admit my age :) ), and I've worked for both the insurance and provider end. I've done consulting for multiple providers, and I've worked the day-to-day operations in both a major metropolitan hospital and for a third party agency which handles multiple providers (of all types from emergency room physicians to DME providers) practicing in multiple states.


More often than not, the delay of you getting a bill for your copay/coinsurance (if the provider's billing department has any semblance of a clue what it's doing) is because your insurance has delayed payment. I've had to appeal claims for upwards of two years on behalf of patients that insurers have denied for the most inane reasons, and it only becomes more complicated when there are more than one insurances involved.


Let me give you a prime example of what I mean:


If you receives services and has Medicare, Medicare bogusly denies, taking a claim in front of an Administrative Law Judge for Medicare can sometimes take 3 years. So, if you received your services in 2000, now it is 2003 by the time the hearing is decided on, the claim paid, and we find out what her copay is. We bill the secondary insurance, they deny the first time out because the claim is so old. We appeal because it was through no fault of our own. This process can take 4-6 months. Now its 2004. There is still a balance left over for a copay which is now billed to the patient.


Now, you're thinking to yourself: Why did you wait 4 years to bill the copay? Because. Depending on the denial, it may have been against Medicare law to bill prior to receiving the approval (this is why I'm using Medicare) to bill the beneficiary.


The world of medical billing becomes more and more complex as the contracts/billing guidelines from the insurers become more complex. It used to be quite simple: you sent in a bill, you got paid. Now, it's not quite that easy, throw in HIPAA and you get a whole new set of issues.


Basically, what I am saying, is that a COMPETENT biller/collector will not turn the bill to self pay until he/she has exhausted all appropriate means of obtaining payment from insurance. This means obtaining all appropriate denials, taking all appropriate discounts, and only billing the patient for the amount dictated by the insurance. This isn't to say that sometimes bills DON'T slip through the cracks, because like anything else, mistakes DO happen.


As patients, we have responsibilities as well:


-Every time you go to your doctor, the hospital etc, make sure they have your current insurance information, current address, current phone number. ESPECIALLY the hospitals! Hospitals have a funky way of somehow "losing" your information.


-If do you receive a bill, make sure you not only send the provider a copy of your current insurance card (and a phone call also), but also send a copy of the bill to your insurance yourself, and follow up with your insurance within 30-45 days to see if it has been paid.


-Know your benefits! Know your plan! If you have a $250 yearly deductible, keep a running tally of what has been applied to that. MAKE SURE that your insurance is properly processing your claims! DO NOT be afraid to request copies of Explanations of benefits (EOB) from your insurance AND from your providers. (This is a part of your medical record, and it is your RIGHT to see these) MAKE SURE that if you are seeing an in-network provider, they are taking the appropriate discounts as indicated on the EOB.


-Watch out for "ancillary" providers being used. This includes things like radiologists, lab services, ER doctors, anesthesiologists. If you are having services performed at an In network hospital, make sure that the ancillary provider is ALSO contracted with your plan!


-Know which services require authorizations and referrals, and make sure that those have been obtained.


It's a lot of work, but if you do all of this and then get bills, you have a lot of leverage over both your insurer and provider. You'll find that resolving the problems will be quite easy and will be in your favor when you keep accurate records. NEVER, EVER rely on your health plan to work in your best interest. The health plan works in its' OWN best interest: keeping costs down.

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More info:


More on "ancillary" services:


Routine lab draws done in your MD office:


-Your MD office does not have the technology nor the capacity to run these types of tests normally. The charges you get from the MD office are normally for the DRAWING of the blood. The blood is then sent off to an off site lab service (ie: Quest Diagnostics) or a hospital lab.


More on insurance:


Contracted vs NON contracted:


If your insurance company is contracted with a provider, there are certain guidelines they have agreed to follow, including, but not limited to:

-they agree to file a claim on your behalf in MOST circumstances (NOT ALL, read YOUR policy!!!!) This is where it becomes ABSOLUTELY VITAL that you ALWAYS provide your most current insurance information at EVERY SINGLE VISIT! The most common reason that providers use for not filing a claim is "no insurance info"

-they agree to accept a certain amount of money for services rendered.


If your insurance company is NOT contracted with a provider, they are NOT obligated to file a claim on your behalf. This is done as a COURTESY to you. YOU are still financially liable, and are responsible for ensuring your insurance pays the bill.

-Discounts applied by your insurance MAY OR MAY NOT be accepted by the provider at the provider's discretion!!!!!!!!!!!!

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WOW. Lots of awesome information Char.


I went to a hospital to have an epidural steriod injection a while ago and after the fact I found out that the hospital was covered by my ins. but not the certain doctor that treated me. I had given them all my ins. info. when I made the appointment and they didn't say I wasn't covered so at the time I thought nothing of it. It turned out that my insurance company would not pay for it so I got billed by the treating doctor for this injection. Do you think there's anything I can do about that now or am I SOL and stuck with the bill?

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I want to ad my 2 cents worth.


My DD is ill and was admitted twice to the hospital. The insurance approved her to be admitted. I received a letter that says it is medically necessary for you to be admitted, but this is no guarantee of payment. Thats the catch!




Over 20k in unpaid bills and included in my BK.


I pay nearly $300.00 a month for coverage through my employer...for what? So you can be admitted and then they don't pay. What do they expect you to lie bleeding on the street corner....


I give up!

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This topic has been around for a long time but it is still very useful and relevant.


If you have any questions or a situation you need help on, please start a new topic.



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I'm sure I've left stuff out, and that you'll have questions. Ask away, and I will do my very best to help you out!


Foshizzle, you are amazing! Thank you so much. I have a serious illness, and I haven't been very proactive (the sheer amount of doctors' visits and paperwork has been overwhelming), but this has inspired me to start going over every week's statements with a fine-toothed comb.

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Thanks FoShizzlel, this is very informative on the one hand and disheartening on the other, seeing that 7 of the tl on my report is medical... i feel SOL! now what? any sugessstion on the best course of action?

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