MEDICAL CLAIMS SUGGESTIONS

Nothing can be more infuriating than spending hours grappling with medical bills and insurance claim forms, only to have the claim rejected weeks later. Unfortunately, now some insurance companies are seizing every opportunity to deny claims in their attempt to hold onto their money for as long as they can. The aim of consumers should be to get their claims paid . . . get them paid promptly . . . and get them paid fully. However, these days, you have to be a savvy consumer who knows just how to play the game in order to accomplish those seemingly simple goals. Here are some suggestions, gleaned from decades of experience in dealing with insurance companies, for how to expedite fair claims processing.

KNOW YOUR POLICY

All too often, people just do not know what their policy covers. Take the case of parents of a one-year-old who submit bills for ear infections, inoculations and other “well baby” care. The policy pays for treatment of ear infections, but denies payment for the other care, saying it only provides well baby care for the first six months of the child’s life. Instead of simply accepting the denial, the parents should check their policy. A growing number of plans now provide such coverage until the child reaches the age of two and some will provide it until the child reaches five or six. However, making a claim for benefits not provided will delay the accompanying legitimate claim payment.

KEEP A LOG OF YOUR CLAIMS

A growing number of companies are using every excuse in the book to delay paying a claim. They will say they never received it, that they received it without any medical bills attached, or minus your signature. Do not assume that no news from the company is good news. Keep track of the date you submitted the claim and the amounts involved. In addition, always keep copies of your bills in case the company says the claim was lost in the mail. That way, you can resubmit the claim with a minimum of hassle.

RECONTACT THE INSURANCE COMPANY

Thirty days from the time you mail in a claim is a reasonable turnaround time for payment of a routine medical expense. By contacting the company after that time, you will know whether there are any administrative problems with the claims...and let the company know that you will not stand for unreasonable delays. If you still do not receive payment, then follow up again in two weeks asking when the claim will be paid. Try to get a commitment as to when the claim will be paid.

KEEP A TELEPHONE LOG

Each time you call, make a record of the name of the person you spoke with, their title, location, date and time. More extensive procedures, such as a heart transplant, may take longer for a company to process. However, since the amounts are larger it is even more important to keep good records.

BEWARE OF CODING MISTAKES

A common problem arises with the five-digit procedure (or CPT) codes that reflect the treatment you receive from a doctor. It is not unusual for an insurance company clerk to enter an incorrect CPT number into the computer. Result: You are reimbursed the wrong amount, or even denied coverage. One way to spot this is to compare the insurer’s code (if it is shown on the statement of benefits forms) with the code on the doctor’s bill and make sure they match. But some insurance companies do not divulge these codes, and may instead say something like “diagnosis does not cover that procedure.” This language should alert you to call the company and ask that it provide the codes for the procedures performed and the codes for the procedures actually reimbursed.

BEWARE OF DOWN-CODING

If multiple procedures are performed at the same office visit, a company may mistakenly assume that less was involved than actually was the case. Suppose you visit a dermatologist to have five moles removed. The company might reimburse for the cost of having only one mole removed. Solution: Compare the doctor’s bills with the insurance payment to be sure the company considered all the charges for treatment rendered at that visit.

WATCH FOR FEE ADJUSTMENTS

Beware of a lowering of what had been considered a “customary and reasonable” fee. Typically, companies will only pay the prevailing fee in your area for a given procedure. Sometimes a company will unilaterally decide to cut what had been considered customary and reasonable . . . and thus reimburse less. If you have been undergoing the same procedure for a while - say, you get regular allergy shots - you will instantly know whether a company is trying to shave its reimbursements, and you can complain.

If it is a non-routine surgical procedure - say, removal of your gallbladder - you may have to do some research before you go ahead with the treatment. Ask your physician what will be charged and then call a few other doctors to find out their fee schedules. As long as your physician is in line with peers, you should not have a problem. But if your doctor’s fee is much higher, you might tell him or her that your company will pay only the prevailing fee...and ask him or her whether he or she is willing to accept the insurance company reimbursement as payment in full. If not, you may have to cough up the extra money yourself, or find another surgeon.

“EXPERIMENTAL” TREATMENT DENIALS

Beware of a denial because a treatment is considered “experimental.” Some insurers refuse payment for bone marrow transplants, routinely used for patients with leukemia and melanoma. They maintain the treatment is experimental. In such cases, it may be necessary to go to court in order to get the insurer to pay up. There is often a two-year lag between the time the medical community starts using a new procedure and when the insurance company agrees to cover it. Sometimes your doctor can shorten that span by interceding on your behalf and presenting an insurer with medical testimony and literature that attests to the efficacy of a particular procedure.

DON’T TAKE NO FOR AN ANSWER

If you feel the company made a mistake in processing your claim, call and complain. If the person with whom you speak dismisses your arguments, ask for a review of your claim. Typically, a review is handled by someone other than a claims clerk and should take no more than four weeks. Often, just having a second opinion will resolve the problem - since many of these decisions are arbitrary judgments. When you call your company, always keep notes on the date and time you called, with whom you spoke, the telephone number at which you reached the person and what transpired during the conversation. This will allow you to monitor the progress of your claim.

Example: If you have not received payment for a strep throat culture, your notes should indicate whether Mr. Smith said he would get back to you in 48 hours, or whether he asked you to provide a more detailed bill with a diagnosis. If Mr. Smith fails to contact you within the agreed-upon time, you should again contact the company, this time by writing to his supervisor.

GO TO COURT IF NECESSARY

If a company still resists paying a legitimate claim, it may be prudent to take legal action. For smaller claims, you can sue in small claims court and act as your own attorney. For larger claims, consult a lawyer or independent claims advisor. Often, simply the notice of a court action is enough to spur a company to settle.