It will take time, organization and persistence, but in the end, chances are good the bill will get paid
“Frustrating” is how people with neuromuscular diseases describe health insurance companies. Essential treatments are not paid because insurers say they are medically unnecessary. Then, after waiting weeks for responses to letters, and hours holding on the phone, the hospitals, doctors and insurance companies point at each other, but expect you to pay the bill!
We encountered these challenges during the two years it took to find the cause of my wife’s mysterious muscle weakness (later diagnosed as a mitochondrial disease). By learning how insurers process claims, staying organized and using the power of relationships, we gained the advantage and got coverage of physical therapy, genetic tests and the right wheelchair. What saddened us was hearing of people needing help more than us, but who gave up due to the insurer.
If you are willing to be proactive, ask tough questions and push forward, these nine tips can give you the advantage in getting scientifically appropriate treatment.
Resolving medical issues can take time. Since much of it is outside your control, you need to act right away. If you check your health insurance website every day, you can learn about problems quickly. It only takes seconds by using a password utility such as LastPass, and can help you get coverage of needed care.
Using this tip, on four occasions I had our insurer correct the same math error on genetic testing claims. By acting quickly, before the lab received the wrong information, we avoided the hassle of an incorrect bill.
Your insurer’s explanation of benefits (EOB) tells you how much you have to pay. For in-network charges, you will have to pay if it is due to your deductible (what you pay before your insurance pays), coinsurance (percent of the reasonable and customary charge you pay, like 10 percent or 20 pecent) or copayment (a set fee you pay like $15 or $25). Before you pay, since math errors are possible, make sure the bill matches the EOB. If not, call the health professional’s office.
Don’t give up when coverage is denied! Find out why. Often, denials are because the procedure code (CPT) used by the doctor did not match the diagnosis code (ICD-9). Asking the insurer if these numbers match will resolve many problems. For us, thousands of dollars of speech/breathing therapy claims were on hold until the neurologist changed the diagnosis code from “fatigue” to “problem with the larynx.” The claims were then paid a few days later.
Further, look for exceptions or limitations, listed in your summary plan description (SPD). This is the thick book about your insurance policy. Ask for this information on the phone and, if necessary, request it by letter.
A large percentage of denials are overturned on appeal; let yours be one of them. After obtaining the information from Tip 3, ask for the insurer’s policy on how they determined medical necessity, and the name and credentials of the person who denied your claim.
Make sure your appeal includes your contact and identifying information. Further, your case needs to be objective, linked to the insurer’s medical necessity policy, and include relevant (but not all) medical records. Make sure to consult with online resources on writing appeals, have it proofread, and send it by certified mail.
H. Jackson Brown, author of Life’s Little Instruction Book, said, “In the confrontation between the stream and the rock, the stream always wins, not by strength, but by perseverance.” Persevere with appeals, since it gives you the opportunity to tell the full story to people with the right training, increasing the chance that you will get coverage for scientifically appropriate medical needs.
There are deadlines, and it takes time to request and review medical records; for people to call back; and for insurers to review material. While being “busy” or “at the hospital” are understandable reasons for delay, waiting to address coverage denials may create more problems in getting your medical bill paid.
If you can stay organized, quickly retrieve information and meet deadlines, it will give you the advantage in getting coverage of the medical care you need. I recommend these tools for staying organized and responding quickly:
By mailing it from the post office, and paying about $5, you will have proof you sent it and proof the insurer received it. You can use the USPS website to download the delivery signature as a PDF file.
When 30 days passed without a response on our physical therapy appeal, I emailed our insurer. Using Acrobat and Evernote, I documented their promises of a response within a week. We finally received three different responses within a two-week period — 157 days after the date of the insurer’s signature on the postal service PDF file. The new health care reform act now addresses these delays.
If you have a rare condition, it is hard to find the right health professionals. Many do not take your insurance and are out-of-network. This situation can be expensive because you owe a larger percentage of the “reasonable and customary” charge, plus the difference between that number and the billed charge. You may think you cannot afford to see that specialist.
Instead, call your insurance’s precertification line. Ask that they be approved for in-network coverage because they’re so highly specialized. You may get transferred to different departments, but persist. If they refuse, appeal so you can get coverage to see the right expert. By taking these steps, we were able to see some famous specialists and run many genetic tests, one of which solved our mystery.
Insurance companies are experienced at denying claims. If your first appeal does not work, ask for help before using up your other appeals.
Because of health care reform, every state is supposed to have an office to help people with appeals. Depending on whether your insurance policy is an individual policy through a small employer, or self-insured through a multistate employer, you can seek assistance through your state insurance commissioner or the U. S. Department of Labor’s Employee Benefits Security Administration. There are also nonprofits that can help people with insurance appeals, and benefit-advocate services that you can hire. Also, do not overlook the importance of having a trusted friend read over anything you send.
Good relationships helped us find a physical therapist who knew how to ensure coverage of a manual wheelchair with power-assist wheels. Good relationships helped us get quick resolution of minor errors with the insurer. Good relationships are why our neurologist’s office promptly sends test results. Good relationships go a long way toward getting medical care covered.
Start with your insurer. If someone on the insurance company’s phone line is helpful, ask for their direct line. Know the names of your health care professionals so you know whom to ask if you need something. When visiting specialists, keep in touch with your original doctors by faxing them an update. Your forms, medicine refills and test results will go faster if you use a local physician with whom you have a relationship.
Your vendors — the labs, wheelchair distributors, pharmacists, etc. — know which health professionals are able to get insurers to cover their services. Having a relationship with your vendors means they are more likely to share this valuable information.
Building relationships will improve your care, secure better coverage and lead to fewer frustrations down the road.
Excerpted from the e-book 9 Tips to Ensure Your Insurer Pays Up by Samir Shah. Shah lives in the New York City area and speaks regularly on using his engineering, organizational and communication skills to find a diagnosis and treatment for his wife.