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Don’t Overpay on Health Insurance Claims

[This is a US-centric post. Every country has a different insurance/medical system, with different ways of handling all this stuff, so this may not even apply to some of you.]

I recently had a physical. My routine bloodwork claim was completely denied by my health insurance carrier, which made me responsible for paying nearly $400.  I called them to find out why, and got a surprising answer: the lab had simply used the wrong diagnostic code – if they would resubmit it with the right code, the claim would be covered (partially – I do have a deductible to meet).

So I called the lab. They said they had used the code the doctor gave them, and needed a correct code from the doctor. I called my doctor’s office. They needed a request from the lab for the correct code.

And I called the lab again, and they did their part, but then the doctor’s office played hot potato with the request for two weeks, doing the “I thought so-and-so handled it” game when I called back.

In the end – many phone calls later – I got my insurance carrier to call the doctor and explain in small words how to fill out the paperwork correctly. I also left a message with my doctor, asking her to make sure the office manager actually did her job since she hadn’t done it so far. And I left a message with the doctor’s office manager, reminding her that I was a patient and stress was not good for my health, so she’d better take care of this.

In the end, all was well, and I only ended up paying what I really owed. I even got a very friendly call from my insurance carrier letting me know everything had been fixed.

Medical and insurance billing goes wrong all the time, and when it does, it’s usually the patient who gets to pay extra. It’s not just fraud or notorious double billing you have to watch out for – it’s silly paperwork errors and office staff who don’t know/care what they’re doing. The problem is, insurance claims and “explanation of benefit” paperwork can be impossible to decipher for the ordinary person. Here’s what I’ve learned to do to protect myself from getting overcharged.

Don’t be shy about questioning bills

What I’ve learned over the years is to call the insurance company every time I’m billed something above my co-pay and can’t immediately understand why. You have a right to keep a customer service rep on the line until you understand in clear language why you owe what you owe. Don’t let them intimidate you or rush you. If they’re no help, ask for a supervisor. You are entitled to understand your benefits, and they are legally required to help you do that.

Sometimes it turns out there’s a weird policy – test A is covered in full, but the test B they perform when the results from test A aren’t clear isn’t – and I’m stuck with the bill. But often it’s just a mistake, and fixing it makes a big difference on my bill. (Not that I should have to do these people’s jobs for them – isn’t it a tad suspicious when a business always makes mistakes in its own favor and never the customer’s?)

  • If there is a mistake somewhere, ask your insurance carrier exactly who you need to call to straighten it out, and exactly what you need to tell them. If you find yourself talking to someone who can’t understand (or isn’t really listening), instruct them to call your insurance carrier for a full explanation. If you get somebody who just wants you to pay the bill and is treating you like a deadbeat, ask for a supervisor. If that doesn’t help, call your insurance carrier or anyone else involved in the situation (your doctor, the lab, whatever) and ask them to get involved.
  • Document everything. Write down who you called, what time on what date, and what you discussed. Hopefully you won’t need it, but…
  • If the process is dragging on, you can write a letter describing everything you’re doing to get the bill corrected, and what specifically other parties are failing to do (include as many names and dates of phone calls as possible), attach a copy of the disputed bill to it, and mail (or email) it to everyone concerned. This may not protect you from being charged late fees (though if you’re dealing with remotely reasonable companies, it very well may), but it will help establish your good intentions if you find yourself dealing with a collection agency or in court. Hopefully it won’t come to that! I’ve never had a billing mistake go that wrong, but I’m sure somewhere at some time it’s happened.

Help the older people you love

As we age, we often have more health insurance claims and a more difficult time reading the fine print. Medicare billing in the US is especially baffling, for those who use it. If you think someone you care about may be overpaying on health care bills, ask them if you can take a look at their recent claims and bills. If you find discrepancies in bills they’ve already paid, you can still challenge the companies involved for reimbursements. You can also help educate them about their benefits as you gain an understanding of them.