September 2006 - Dr. Mary Harris

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Last year, I filed the paperwork to be reimbursed by my insurance company after a simple doctor visit for an annual physical. The physical was done at a medical facility outside of my state of residence. Before proceeding with my appointment, I contacted my insurance company and was assured that the exam would be covered. When it came time to fill out the claim form, I soldiered on through the maze of paperwork. My wrist may have been a little tired when I was done, but it turns out filling out the mountain of paperwork was actually the easy part.

Once I filed the paperwork, my insurance company found every reason imaginable not to pay the claim. First, they said I'd submitted the paperwork to the wrong office and they sent it back to me. I resubmitted it to the appropriate office, only to be informed that they never received the claim. When I proved to them that they had received the claim by producing a certified mailing receipt with their employee's signature, they said the claim was not covered under my policy. When I pointed out that according to their summary of benefits outlined in their policy manual, my annual physical is 100 percent covered, they saw the error of their ways and finally cut a check. When I didn't receive the check in a timely manner, I called only to find out that they had mailed my check to the wrong address!

After several more exchanges with the insurance company (the entire process stretched over six months), I finally received my reimbursement. Although this may seem like a long time, I've been told that many consumers simply give up-- exasperated because they don't have the stamina to initiate or complete the process to appeal a claim that's been denied payment.

My encounter with the insurance company did make me think about those that are ill-prepared to challenge the system. The elderly and chronically ill may not be up to the challenge of chasing their money. Folks receiving Medicare can appeal, but the process takes 45 days. A lot can happen in 45 days. And if you're really sick and need your reimbursement to buy food or purchase medications, the appeals process can mean the difference between life and death–literally.

Thankfully I survived my ordeal, and while that in no way makes me an expert, I can pass on the useful advice I learned along the way:

  • Take the time to read your policy and/or your policy manual before you get sick and need to file a claim. Many people don't do this until their claim is denied
  • Be persistent. Getting discouraged won't get you paid. But like his cousin the "early bird", the "relentless bird" gets the worm, too.
  • Expect considerable time to pass before you collect on a disputed claim. Many states have prompt-pay laws, but these laws only apply to error-free submission claims. And unfortunately, even if you submit a claim with no errors, there's still no guarantee the insurance company won't flagrantly disobey a state's prompt-pay law.
  • Keep detailed records and make multiple copies of everything. If getting reimbursed turns into a tangle of red tape, the party with the best records stands the best chance of cutting through the confusion. Note the name and contact information of anyone you talk with about your case. Keep a brief summary of your calls. If the conversations are in insurance company double-speak that makes your head spin, ask the insurer explain things in simpler terms that you understand.
  • Send your initial claim via certified mail.
  • Call within two weeks to find out the status of your claim. Don't expect the insurance company to stay on top of your reimbursement; that's your responsibility.
  • Do your homework. If a claim is denied, find out why. There may be a simple reason, such as an incorrect code or a missing physician's referral.
  • Watch the calendar. If your claim is denied, you'll probably only have 30 to 90 days to appeal. After that time, it is significantly more difficult, perhaps impossible, to appeal.
  • Consider getting help. If your case is particularly complicated, it might be time to look into getting assistance from a medical claims company. They have the experience necessary to correct miscoded procedures, hunt down physicians who authorize treatment without informing the insurance company and coordinate coverage between multiple insurers. Some states will refer you to the state insurance department that will help you through the process or investigate a company if necessary.
  • Try to keep your cool, buckle yourself in and hold on for the ride!

With you on your Journey To Wellness,
Dr. Mary Harris

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