Fighting Insurance

[catbus]

So, I kind of have a Cadillac health care plan. Basically, everything's included and covered. I always review my EOB from my insurance provider, and hang onto it for a few months in case any bills come in. If I receive a bill, I match it up to my EOB first to make sure they jibe. I've caught some errors this way. There's a lab that's apparently notorious for overbilling (Cellnetix), and just while I was pregnant I was billed for them for the difference between the amount they originally billed my insurance, and the insurance company's settled amount (for example, they bill insurance $100 for a test, insurance says they pay $75 for that test, EOB shows the other $25 as a provider write-off with patient responsibility of $0, but then Cellnetix bills me for that $25). Those were both easy--I just called up Cellnetix and said hey, this is incorrect, and they verified it was a billing error.
For denied claims, I call the insurance company for the exact reason the claim was denied. Sometimes they immediately realize it was an input error on their part and the claim should have been covered. Other times, it's that the provider's office didn't use the right code, in which case I have my insurance company tell me which code(s) would have been covered, and send a message or call my provider's office to discuss them resubmitting the claim with a corrected code. For example, my breast pump should have been covered by my insurance, but unfortunately the claim was submitted under a weird code that didn't even apply to my situation. The EOB came back saying "this service is not covered under this plan," but since I knew pumps were covered, I called in and had them look up the claim, tell me what code was billed, and what codes would have been covered, then asked my provider to resubmit using a valid code that applied to me (in my case, "returning to work").

In dealing with all this, it pays to be very polite but very persistent.

[niq]

Some people fight parking tickets, i fight insurance bills. I have a high tolerance for this stuff, i sort of feel like they need to be taught a lesson . The only way to do it is get everyone on the line.

step one is make sure you know how to make a three way call from whatever phone you're calling from.

Step two is call the provider and find the right person to talk to. This is a NIGHTMARE with UWMC. Start with the number on the bill from the provider, then the front desk at your particular department where you received the service.

Step three is once you have the right person, conference in your insurer. you may have to strong arm the provider a little bit, like "can i conference in the insurer and the three of us sort this out over the phone?" They want to wriggle out of it because once everyone is on the phone they can't pass the buck except to the physician, and they don't want to have to involve the physician.

Now you have everyone on the phone and you are there, so they usually sort things it pretty quick.

So far we have had the following fuckups:
* ER billed us full price because insurer refused to pay for cat bite ER visit because insurer didn't get the "who can we sue" survey by the time the ER sent the claim. Two calls to insurer, then we get the right bill.
* no one could give us a straight answer on what was and wasn't covered as far as genetic screening. 3 calls to the insurer, seven to UWMC. I still don't know how they came up with that number.
* insurer will pay for regular std testing, but not std testing "in the context of pregnancy". Two calls to insurer, three calls to several UWMC departments who say they can't do anything, msniq brings it up with the obgyn, she says she'll fix the Billing code and complains about insurance companies. UW just sent us a past due notice for the this bill even though we called and asked them to re-process the claim two weeks ago.
* cholesterol tests are preventive and covered. But a blood panel us not. Am i supposed to walk into every appointment saying "please advise me of any services that are outside of Medicare categories 1 and 2"?

Sometimes I want to move to Denmark so bad...

I blame all wring words on Swype

ETA: @jennuine I should add that sometimes I call the insurer first and try to understand the situation before the three-way call,

[cdmay]

Niq, one thing you can do is at any given appt., ask what is planned for the next appt. in terms of tests, screenings, etc. Then at the desk, ask for the billing codes. You can call insurance to ask what will be charge for those codes and with that information know what to expect and make informed decisions of consent.
I examine the EOB and call for any questions (they really provide very little information). Then when i get the bill, i compare to the EOB. My course of action depends on who made the what sort of mistake.

[niq]

UGH, the jokers at the insurance company haven't gotten the updated bill from the jokers at uwmc. It's been two weeks ... did you send it by stapling it to a three-toed sloth?!

[jennlin]

i keep all my EOB's in a folder, and when i get the bills for them, i match them up. i've never fought insurance, bought i've fought the dr office before.

i used to work in insurance, am a little bit of an insurance nerd, so i've always been waiting for my insurance to mess up, but they haven't yet.